Provider Demographics
NPI:1295230316
Name:KIM, DIANA (BACHELORS)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:BACHELORS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 WHITTLE CT
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-3461
Mailing Address - Country:US
Mailing Address - Phone:209-678-4385
Mailing Address - Fax:
Practice Address - Street 1:1115 14TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1003
Practice Address - Country:US
Practice Address - Phone:209-572-2589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18-51927106E00000X
CARBT-18-51927106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst