MEDICARE: SOPHIA P KIM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst		NY

General Provider Information

NPI Number	:	1174499156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHIA P KIM

Provider Business Mailing Address
First Line	:	239 FIR GROVE RD
Second Line	:
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-4803
Country	:	US
Telephone Number	:	631-896-2123
Fax Number	:

Provider Business Practice Location Address
First Line	:	239 FIR GROVE RD
Second Line	:
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-4803
Country	:	US
Telephone Number	:	631-896-2123
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2025
Last Update Date	:	10/15/2025

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Directions to “ SOPHIA P KIM ” Practice Location

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