Provider Demographics
NPI:1124363916
Name:KIM, CHANGYOUNG
Entity Type:Individual
Prefix:
First Name:CHANGYOUNG
Middle Name:
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 1:14945 NORTHERN BLVD
Mailing Address - Street 2:APT 3N
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-3897
Mailing Address - Country:US
Mailing Address - Phone:718-702-8085
Mailing Address - Fax:
Practice Address - Street 1:14945 NORTHERN BLVD
Practice Address - Street 2:APT 3N
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-3897
Practice Address - Country:US
Practice Address - Phone:718-702-8085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032517225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist