Provider Demographics
NPI:1457818676
Name:KIM, MINKYUNG (LCAT)
Entity Type:Individual
Prefix:
First Name:MINKYUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 E 36TH ST APT 2B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-3419
Mailing Address - Country:US
Mailing Address - Phone:917-444-0061
Mailing Address - Fax:
Practice Address - Street 1:22 E 36TH ST APT 2B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3419
Practice Address - Country:US
Practice Address - Phone:917-444-0061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-24
Last Update Date:2019-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001918221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Single Specialty