Healthcare Provider Details

I. General information

NPI: 1407791882
Provider Name (Legal Business Name): GUM JU SIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19038A 69TH AVE APT 1A
FRESH MEADOWS NY
11365-3714
US

IV. Provider business mailing address

19038A 69TH AVE APT 1A
FRESH MEADOWS NY
11365-3714
US

V. Phone/Fax

Practice location:
  • Phone: 516-743-9233
  • Fax:
Mailing address:
  • Phone: 516-743-9233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number022445
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: