Provider Demographics
NPI:1104025022
Name:YIM, STACEY ANN
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:ANN
Last Name:YIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1841 FORT WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-1909
Mailing Address - Country:US
Mailing Address - Phone:808-778-8661
Mailing Address - Fax:
Practice Address - Street 1:91-1841 FORT WEAVER RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-1909
Practice Address - Country:US
Practice Address - Phone:808-778-8661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI945103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical