Provider Demographics
NPI:1619759040
Name:KIM, OLESYA
Entity Type:Individual
Prefix:
First Name:OLESYA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 ZENA RD STE 2
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:12498-2627
Mailing Address - Country:US
Mailing Address - Phone:845-679-8650
Mailing Address - Fax:
Practice Address - Street 1:404 ZENA RD STE 2
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498-2627
Practice Address - Country:US
Practice Address - Phone:845-679-8650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP124041106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist