Provider Demographics
NPI:1063475259
Name:KIM, SOONIE ANN (PHD)
Entity Type:Individual
Prefix:MS
First Name:SOONIE
Middle Name:ANN
Last Name:KIM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 SW MACADAM AVE
Mailing Address - Street 2:#580
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6103
Mailing Address - Country:US
Mailing Address - Phone:503-231-7854
Mailing Address - Fax:503-231-8153
Practice Address - Street 1:5200 SW MACADAM AVE
Practice Address - Street 2:#580
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-6103
Practice Address - Country:US
Practice Address - Phone:503-231-7854
Practice Address - Fax:503-231-8153
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1175103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR158831Medicaid
OR158831Medicaid
000TCPHCMedicare ID - Type Unspecified