MEDICARE: JOHANAH Y KANG 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	PY60805166	WA
2	103G00000X	Clinical Neuropsychologist	PY60805166	WA

General Provider Information

NPI Number	:	1588163208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHANAH Y KANG PHD

Provider Business Mailing Address
First Line	:	2013 SOUTH 19TH STREET
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98405
Country	:	US
Telephone Number	:	253-383-3355
Fax Number	:	253-383-3627

Provider Business Practice Location Address
First Line	:	2013 SOUTH 19TH STREET
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98405
Country	:	US
Telephone Number	:	253-383-3355
Fax Number	:	253-383-3627

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

Provider Enumeration Date	:	02/08/2018
Last Update Date	:	02/08/2018

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