Healthcare Provider Details

I. General information

NPI: 1578604534
Provider Name (Legal Business Name): MYONG KIM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2007
Last Update Date: 03/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 N WESTERN AVE
LOS ANGELES CA
90027-5615
US

IV. Provider business mailing address

1816 3/4 SANTA YNEZ ST
LOS ANGELES CA
90026-4277
US

V. Phone/Fax

Practice location:
  • Phone: 323-957-7421
  • Fax: 323-463-3325
Mailing address:
  • Phone: 818-640-7633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: