Provider Demographics
NPI:1114301934
Name:KIM, JUNYEON PAUL (LCSW/QMHP)
Entity Type:Individual
Prefix:
First Name:JUNYEON
Middle Name:PAUL
Last Name:KIM
Suffix:
Gender:M
Credentials:LCSW/QMHP
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW/QMHP
Mailing Address - Street 1:3439 NE SANDY BLVD # 646
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1959
Mailing Address - Country:US
Mailing Address - Phone:803-360-7783
Mailing Address - Fax:971-251-1933
Practice Address - Street 1:2355 STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4541
Practice Address - Country:US
Practice Address - Phone:803-360-7783
Practice Address - Fax:971-251-1933
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL112571041C0700X
OR101YM0800X
ORA5807104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500734777Medicaid