Provider Demographics
NPI:1427371459
Name:KIM, MYUNG JIN
Entity Type:Individual
Prefix:
First Name:MYUNG JIN
Middle Name:
Last Name:KIM
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 1:9378 OLIVE BLVD STE 317
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-3224
Mailing Address - Country:US
Mailing Address - Phone:314-994-9344
Mailing Address - Fax:314-994-3007
Practice Address - Street 1:9378 OLIVE BLVD STE 317
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3224
Practice Address - Country:US
Practice Address - Phone:314-994-9344
Practice Address - Fax:314-994-3007
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009036114101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2009036114OtherLPC, STATE OF MISSOURI