=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801234331
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIMINA PSYCHOTHERAPY INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2013
-----------------------------------------------------
Last Update Date | 06/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 185 PIER AVE SUITE 104
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90405-5331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-285-3259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 185 PIER AVE SUITE 104
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90405-5331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-285-3259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JINSOO LIM
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 310-804-8676
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | MFC44375
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MFC44375
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC44375
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------