Healthcare Provider Details

I. General information

NPI: 1497127047
Provider Name (Legal Business Name): REBECCA ANNE WYCKOFF KIM PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4447 36TH ST S
ARLINGTON VA
22206-1817
US

IV. Provider business mailing address

1350 CONNECTICUT AVE NW STE 602
WASHINGTON DC
20036-1716
US

V. Phone/Fax

Practice location:
  • Phone: 502-541-1933
  • Fax:
Mailing address:
  • Phone: 502-541-1933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY200001221
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: