Provider Demographics
NPI:1275855090
Name:SHIM, SUN BO
Entity Type:Individual
Prefix:
First Name:SUN BO
Middle Name:
Last Name:SHIM
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 1:262 N LOS ROBLES AVE
Mailing Address - Street 2:#115
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1331 W AVENUE J
Practice Address - Street 2:SUITE 202
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2942
Practice Address - Country:US
Practice Address - Phone:661-940-9094
Practice Address - Fax:661-951-1030
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-21
Last Update Date:2010-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 62315106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist