Provider Demographics
NPI:1508627845
Name:YIM, JUSTIN HARRISON
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:HARRISON
Last Name:YIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JUSTIN
Other - Middle Name:HARRISON
Other - Last Name:YIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:21320 HIDDEN PINES DR
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3531
Mailing Address - Country:US
Mailing Address - Phone:909-656-7165
Mailing Address - Fax:
Practice Address - Street 1:21320 HIDDEN PINES DR
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3531
Practice Address - Country:US
Practice Address - Phone:909-656-7165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374700000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374700000XNursing Service Related ProvidersTechnician