=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568110823
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENUINE DIALOGUE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2022
-----------------------------------------------------
Last Update Date | 05/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4445 CORPORATION LN STE 264
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-3262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-341-4771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4445 CORPORATION LN STE 264
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-3262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | YOUNGHWAN KIM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-495-3950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------