Provider Demographics
NPI:1649736265
Name:KIM, SOO (AMY) JIN (MS)
Entity Type:Individual
Prefix:
First Name:SOO (AMY)
Middle Name:JIN
Last Name:KIM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JIN
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:11037 WARNER AVE # 339
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4007
Mailing Address - Country:US
Mailing Address - Phone:714-848-8319
Mailing Address - Fax:714-596-6274
Practice Address - Street 1:1901 CARNEGIE AVE STE 1C
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5504
Practice Address - Country:US
Practice Address - Phone:800-273-4292
Practice Address - Fax:714-596-6274
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA1-22-62832103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician