Healthcare Provider Details

I. General information

NPI: 1962768986
Provider Name (Legal Business Name): MINA KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MINA PAK

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 W LINCOLN AVE STE 100
ANAHEIM CA
92805-2912
US

IV. Provider business mailing address

451 W LINCOLN AVE STE 100
ANAHEIM CA
92805-2912
US

V. Phone/Fax

Practice location:
  • Phone: 714-503-6550
  • Fax:
Mailing address:
  • Phone: 714-503-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number92575
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: