Healthcare Provider Details

I. General information

NPI: 1750821567
Provider Name (Legal Business Name): MIMI KIM-VASS LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 SHADY RUN RD
YOUNGSTOWN OH
44502-2770
US

IV. Provider business mailing address

2800 SHADY RUN RD
YOUNGSTOWN OH
44502-2770
US

V. Phone/Fax

Practice location:
  • Phone: 234-228-8235
  • Fax:
Mailing address:
  • Phone: 234-228-8235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.1000481
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: