Healthcare Provider Details

I. General information

NPI: 1396271185
Provider Name (Legal Business Name): SOO M KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 SW 136TH ST
BURIEN WA
98166-1214
US

IV. Provider business mailing address

10501 8TH AVE NE APT 210
SEATTLE WA
98125-7230
US

V. Phone/Fax

Practice location:
  • Phone: 206-242-1698
  • Fax:
Mailing address:
  • Phone: 206-326-0816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberCG 60553309
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: