Provider Demographics
NPI:1164177465
Name:KIM, ANGELA RAE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:RAE
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 1:1021 CROSS COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-2113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 E WILSON BRIDGE RD STE 327
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-1115
Practice Address - Country:US
Practice Address - Phone:614-450-2889
Practice Address - Fax:614-413-2564
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2023-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHM.2300257106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist