Provider Demographics
NPI:1316384191
Name:KIM, TAE SUN (MA)
Entity Type:Individual
Prefix:
First Name:TAE SUN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 PIERCE ST APT 1523
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1013
Mailing Address - Country:US
Mailing Address - Phone:765-760-5493
Mailing Address - Fax:
Practice Address - Street 1:2222 BANCROFT WAY
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-4304
Practice Address - Country:US
Practice Address - Phone:510-642-9336
Practice Address - Fax:510-642-2368
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health