Provider Demographics
NPI:1083968002
Name:SON, MIN SOO
Entity Type:Individual
Prefix:
First Name:MIN SOO
Middle Name:
Last Name:SON
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 1:2410 W ORANGETHORPE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4260
Mailing Address - Country:US
Mailing Address - Phone:310-658-2763
Mailing Address - Fax:
Practice Address - Street 1:3727 W 6TH ST STE 210
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-5108
Practice Address - Country:US
Practice Address - Phone:213-637-1080
Practice Address - Fax:213-637-1075
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health