Healthcare Provider Details

I. General information

NPI: 1689355828
Provider Name (Legal Business Name): MICHELLE KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 RITCHIE HWY STE 2001
SEVERNA PARK MD
21146-4163
US

IV. Provider business mailing address

815 RITCHIE HWY STE 112
SEVERNA PARK MD
21146-4192
US

V. Phone/Fax

Practice location:
  • Phone: 667-500-4556
  • Fax:
Mailing address:
  • Phone: 667-500-4556
  • Fax: 443-443-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP15628
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberATG203
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: