Provider Demographics
NPI:1871963223
Name:KIM, ALEXIS (OTR/L)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7408 EDGEWOOD AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55428-1440
Mailing Address - Country:US
Mailing Address - Phone:651-333-0785
Mailing Address - Fax:
Practice Address - Street 1:1879 FERONIA AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3549
Practice Address - Country:US
Practice Address - Phone:651-333-0785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-28
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104158225X00000X
IA002272225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist