Provider Demographics
NPI:1902198575
Name:TAE, KYUNG-RAN (OT/L)
Entity type:Individual
Prefix:MS
First Name:KYUNG-RAN
Middle Name:
Last Name:TAE
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 S CITRUS AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4748
Mailing Address - Country:US
Mailing Address - Phone:714-714-5597
Mailing Address - Fax:714-534-0004
Practice Address - Street 1:9764 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1615
Practice Address - Country:US
Practice Address - Phone:714-534-0007
Practice Address - Fax:714-534-0004
Is Sole Proprietor?:No
Enumeration Date:2011-05-13
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT10347225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist