Provider Demographics
NPI:1275009904
Name:KIM, ANNIE
Entity Type:Individual
Prefix:
First Name:ANNIE
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 1:804 W GEORGE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-9284
Mailing Address - Country:US
Mailing Address - Phone:310-483-8652
Mailing Address - Fax:
Practice Address - Street 1:804 W GEORGE ST APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-9284
Practice Address - Country:US
Practice Address - Phone:310-483-8652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-20
Last Update Date:2018-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.013660235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist