Healthcare Provider Details

I. General information

NPI: 1063294866
Provider Name (Legal Business Name): MIJIN KIM CREATIVE ARTS THERAPY PSYCHOTHERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 10/17/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N. CENTRAL PARK AVENUE SUITE 340
HARTSDALE NY
10530
US

IV. Provider business mailing address

21 CAROLYN WAY
PURDYS NY
10578-1011
US

V. Phone/Fax

Practice location:
  • Phone: 917-767-5237
  • Fax:
Mailing address:
  • Phone: 917-767-5237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. MIJIN KIM
Title or Position: OWNER
Credential: DA, LCAT
Phone: 917-767-5237