Provider Demographics
NPI:1508095795
Name:KIM, EUNICE (PHD)
Entity Type:Individual
Prefix:
First Name:EUNICE
Middle Name:
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:PO BOX 25852
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-0852
Mailing Address - Country:US
Mailing Address - Phone:310-740-0214
Mailing Address - Fax:310-882-6807
Practice Address - Street 1:11911 SAN VICENTE BLVD STE 280
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6611
Practice Address - Country:US
Practice Address - Phone:310-740-0214
Practice Address - Fax:310-882-6807
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21462103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY214620Medicaid
CAPSY214620Medicaid
CAEY751ZMedicare PIN