MEDICARE: REBECCA ANNE WYCKOFF KIM PHD

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	103TC0700X	Clinical Psychologist	PSY200001221	DC
2	103T00000X	Psychologist

General Provider Information

NPI Number	:	1497127047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA ANNE WYCKOFF KIM PHD

Provider Business Mailing Address
First Line	:	1350 CONNECTICUT AVE NW STE 602
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20036-1716
Country	:	US
Telephone Number	:	502-541-1933
Fax Number	:

Provider Business Practice Location Address
First Line	:	4447 36TH ST S
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22206-1817
Country	:	US
Telephone Number	:	502-541-1933
Fax Number	:

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

Provider Enumeration Date	:	10/22/2015
Last Update Date	:	06/01/2022

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