Healthcare Provider Details

I. General information

NPI: 1104619592
Provider Name (Legal Business Name): WONHA KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2025
Last Update Date: 06/28/2025
Certification Date: 06/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 COOLIDGE AVE
OAKLAND CA
94602-3311
US

IV. Provider business mailing address

2171 TALLADEGA CT
SPARKS NV
89436-8704
US

V. Phone/Fax

Practice location:
  • Phone: 510-482-2244
  • Fax:
Mailing address:
  • Phone: 775-636-5303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPCC19740
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: