Provider Demographics
NPI:1003104431
Name:LIM, MAGDALENE L (PSYD)
Entity Type:Individual
Prefix:
First Name:MAGDALENE
Middle Name:L
Last Name:LIM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4863 N NEVADA AVE
Mailing Address - Street 2:STE 321
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-3951
Mailing Address - Country:US
Mailing Address - Phone:719-255-8002
Mailing Address - Fax:719-255-8006
Practice Address - Street 1:4863 N NEVADA AVE
Practice Address - Street 2:STE 321
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3951
Practice Address - Country:US
Practice Address - Phone:719-255-8002
Practice Address - Fax:719-255-8006
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021384-1103T00000X
COPSY 4438103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist