Provider Demographics
NPI:1235822693
Name:KIM, SERENA (ACMHC)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 S VALENTINA BAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3394
Mailing Address - Country:US
Mailing Address - Phone:801-319-7424
Mailing Address - Fax:801-319-7424
Practice Address - Street 1:80 S ORANGE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-3066
Practice Address - Country:US
Practice Address - Phone:801-596-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13398160-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health