Healthcare Provider Details

I. General information

NPI: 1720411473
Provider Name (Legal Business Name): SHANNA YONG KIM M.A., M.S., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE # 7G26
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

139 LEESE ST UNIT A
SAN FRANCISCO CA
94110-5827
US

V. Phone/Fax

Practice location:
  • Phone: 628-206-8426
  • Fax:
Mailing address:
  • Phone: 408-891-1435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: