Healthcare Provider Details

I. General information

NPI: 1790815256
Provider Name (Legal Business Name): YOUNGSHIN TERESA KIM MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ALEXIAN DR # 110
SAN JOSE CA
95116-1901
US

IV. Provider business mailing address

2101 ALEXIAN DR # 110
SAN JOSE CA
95116-1901
US

V. Phone/Fax

Practice location:
  • Phone: 408-272-6594
  • Fax: 408-272-6569
Mailing address:
  • Phone: 408-272-6594
  • Fax: 408-272-6569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 41757
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: