Provider Demographics
NPI:1659973246
Name:KIM, YOUNGSUK
Entity Type:Individual
Prefix:DR
First Name:YOUNGSUK
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 1:1 CONSTITUTION PLZ STE 140
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-2025
Mailing Address - Country:US
Mailing Address - Phone:617-899-5456
Mailing Address - Fax:
Practice Address - Street 1:1 CONSTITUTION PLZ STE 140
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-2025
Practice Address - Country:US
Practice Address - Phone:617-899-5456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01899103TC0700X
MA11390103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical