Provider Demographics
NPI:1659328524
Name:SO, KYUNG WHA (PH D)
Entity Type:Individual
Prefix:DR
First Name:KYUNG
Middle Name:WHA
Last Name:SO
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2956 SU SIEMPRE PL
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-7363
Mailing Address - Country:US
Mailing Address - Phone:213-500-0838
Mailing Address - Fax:760-747-5143
Practice Address - Street 1:3540 WILSHIRE BLVD
Practice Address - Street 2:SUITE # PH 16
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2307
Practice Address - Country:US
Practice Address - Phone:213-500-0838
Practice Address - Fax:760-747-5143
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPSY 20313103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP20313Medicare PIN