Provider Demographics
NPI:1962077917
Name:SHIN, SOOMIN SARAH (PT)
Entity type:Individual
Prefix:
First Name:SOOMIN
Middle Name:SARAH
Last Name:SHIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 JAYNES PL
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-8427
Mailing Address - Country:US
Mailing Address - Phone:714-788-4729
Mailing Address - Fax:
Practice Address - Street 1:7941 BEACH BLVD STE J
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-1900
Practice Address - Country:US
Practice Address - Phone:714-736-6855
Practice Address - Fax:714-736-6824
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist