Healthcare Provider Details

I. General information

NPI: 1356114623
Provider Name (Legal Business Name): KRISTEN KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 RIVER RD, STE 32 BOX 180
EDGEWATER NJ
07020
US

IV. Provider business mailing address

725 RIVER RD, STE 32 BOX 180
EDGEWATER NJ
07020
US

V. Phone/Fax

Practice location:
  • Phone: 917-727-1896
  • Fax:
Mailing address:
  • Phone: 917-727-1896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06275700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: