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General NPI Number Information
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NPI Number | 1275222127
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Entity Type | Individual
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Provider Name | SUNGJIN IM PHD
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Gender | Male
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Dates
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Enumeration Date | 05/05/2023
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Last Update Date | 05/05/2023
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Provider Practice Location Address
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Address Line | 1906 COLLEGE HEIGHTS BLVD # 3021
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City | BOWLING GREEN
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State | KY
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Zip | 42101-1000
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Country | US
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Telephone | 775-393-0307
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Fax |
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Provider Business Mailing Address
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Address Line | 1906 COLLEGE HEIGHTS BLVD # 3021
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City | BOWLING GREEN
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State | KY
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Zip | 42101-1000
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 024766
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 276794
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License Number State | KY
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