Provider Demographics
NPI:1568938561
Name:KIM, TAE (LCSW)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 333 BOX 1551
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96251-0016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BLD S370
Practice Address - Street 2:CAMP HUMPHREYS BEHAVIORAL HEALTH CLINIC
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96251-0016
Practice Address - Country:US
Practice Address - Phone:315-737-5803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI43251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical