Healthcare Provider Details

I. General information

NPI: 1215634712
Provider Name (Legal Business Name): MO SE KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2023
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6930 BEACH BLVD UNIT L141
BUENA PARK CA
90621-6856
US

IV. Provider business mailing address

6060 N PARAMOUNT BLVD
LONG BEACH CA
90805-3711
US

V. Phone/Fax

Practice location:
  • Phone: 714-872-2291
  • Fax:
Mailing address:
  • Phone: 562-630-8672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5840
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number16606
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number16606
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: