Provider Demographics
NPI:1316361728
Name:KIM, SAMUEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 N CLARE AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-9194
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14800 QUORUM DR STE 274
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-1420
Practice Address - Country:US
Practice Address - Phone:214-885-5467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015832103T00000X
TX71316103TS0200X
COPSY.0005752103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool