Provider Demographics
NPI:1568932655
Name:TA, ANNA KIM (MS)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:KIM
Last Name:TA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19915 BOTHELL EVERETT HWY APT 1103
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8167
Mailing Address - Country:US
Mailing Address - Phone:408-644-2286
Mailing Address - Fax:
Practice Address - Street 1:16530 AVONDALE RD NE
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98077-9178
Practice Address - Country:US
Practice Address - Phone:253-294-0783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831541770OtherBEHAVIOR ANALYST