Healthcare Provider Details

I. General information

NPI: 1639003270
Provider Name (Legal Business Name): SELAH KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 N NORTHWEST HWY STE 147
PARK RIDGE IL
60068-3263
US

IV. Provider business mailing address

7817 N OCONTO AVE
NILES IL
60714-2905
US

V. Phone/Fax

Practice location:
  • Phone: 847-610-9798
  • Fax:
Mailing address:
  • Phone: 847-204-5957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: