Provider Demographics
NPI:1477803781
Name:KIM, MI KYONG
Entity Type:Individual
Prefix:
First Name:MI
Middle Name:KYONG
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 1:5422 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121
Mailing Address - Country:US
Mailing Address - Phone:415-255-2531
Mailing Address - Fax:
Practice Address - Street 1:555 NORTHGATE DRIVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3680
Practice Address - Country:US
Practice Address - Phone:415-491-5700
Practice Address - Fax:415-491-5750
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 61859101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health