Provider Demographics
NPI:1083326953
Name:KIM, SOO KON
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:KON
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 CEDAR LN STE 3B
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3441
Mailing Address - Country:US
Mailing Address - Phone:201-541-8600
Mailing Address - Fax:
Practice Address - Street 1:310 CEDAR LN STE 3B
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-3441
Practice Address - Country:US
Practice Address - Phone:201-541-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist