Provider Demographics
NPI:1124582887
Name:KIM, YENA
Entity Type:Individual
Prefix:
First Name:YENA
Middle Name:
Last Name:KIM
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 1:18946 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15242 MATISSE CIR
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-4731
Practice Address - Country:US
Practice Address - Phone:714-403-7988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2024-01-30
Deactivation Date:2023-10-16
Deactivation Code:
Reactivation Date:2024-01-30
Provider Licenses
StateLicense IDTaxonomies
FLSA22038235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist