Provider Demographics
NPI:1417106626
Name:KIM, MIRIM (PT)
Entity Type:Individual
Prefix:MS
First Name:MIRIM
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192-20C 67TH AVE
Mailing Address - Street 2:2B
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365
Mailing Address - Country:US
Mailing Address - Phone:718-938-3364
Mailing Address - Fax:718-795-1672
Practice Address - Street 1:192 20C 67TH AVE
Practice Address - Street 2:2B
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365
Practice Address - Country:US
Practice Address - Phone:718-938-3364
Practice Address - Fax:718-795-1672
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024034225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist