Provider Demographics
NPI:1205356029
Name:KIM, ANGIE EUNJI
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:EUNJI
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 1:1513 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-4013
Mailing Address - Country:US
Mailing Address - Phone:714-526-4673
Mailing Address - Fax:714-526-3700
Practice Address - Street 1:1513 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-4013
Practice Address - Country:US
Practice Address - Phone:714-526-4673
Practice Address - Fax:714-526-3700
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4839101YM0800X
CA104796106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health