Provider Demographics
NPI:1275175242
Name:NAMU INTEGRATIVE THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:NAMU INTEGRATIVE THERAPY SERVICES, LLC
Other - Org Name:NAMU INTEGRATIVE THERAPY SERVICES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HYE-KYONG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP, SEP
Authorized Official - Phone:612-424-0051
Mailing Address - Street 1:1145 GRAND AVE # 101
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2629
Mailing Address - Country:US
Mailing Address - Phone:612-424-0051
Mailing Address - Fax:
Practice Address - Street 1:1145 GRAND AVE # 101
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2629
Practice Address - Country:US
Practice Address - Phone:612-594-6910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-11
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1962759217Medicaid