Provider Demographics
NPI:1649580002
Name:KIM, MARK (LMHC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1654 FICUS POINT DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1530
Mailing Address - Country:US
Mailing Address - Phone:626-430-8472
Mailing Address - Fax:
Practice Address - Street 1:1600 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE 201U
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4149
Practice Address - Country:US
Practice Address - Phone:626-430-8472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7246634101YM0800X
FLMH 13682101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health