Basic Information
| Provider Information | |||||||||
| NPI: | 1407511009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | TAE KYUNG | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 VALLEY AVE UNIT 104 | ||||||||
| Address2: | |||||||||
| City: | ELMSFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105233023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017149481 | ||||||||
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| Practice Location | |||||||||
| Address1: | 57 W BURNSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104534038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187164400 | ||||||||
| FaxNumber: | 7189242678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2021 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 025464-01 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.