Provider Demographics
NPI:1497127047
Name:KIM, REBECCA ANNE WYCKOFF (PHD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE WYCKOFF
Last Name:KIM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 CONNECTICUT AVE NW STE 602
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20036-1716
Mailing Address - Country:US
Mailing Address - Phone:502-541-1933
Mailing Address - Fax:
Practice Address - Street 1:4447 36TH ST S
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22206-1817
Practice Address - Country:US
Practice Address - Phone:502-541-1933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY200001221103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist