Healthcare Provider Details

I. General information

NPI: 1801559133
Provider Name (Legal Business Name): MINA KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8280 WILLOW OAKS CORPORATE DR
FAIRFAX VA
22031-4518
US

IV. Provider business mailing address

8280 WILLOW OAKS CORPORATE DR
FAIRFAX VA
22031-4518
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-4300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: