Provider Demographics
NPI:1679244149
Name:KIM, MI JIN
Entity Type:Individual
Prefix:
First Name:MI
Middle Name:JIN
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 1:44980 HAMPTONS BLVD APT 213
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-4752
Mailing Address - Country:US
Mailing Address - Phone:703-678-9161
Mailing Address - Fax:
Practice Address - Street 1:44980 HAMPTONS BLVD APT 213
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-4752
Practice Address - Country:US
Practice Address - Phone:703-678-9161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09361225XP0019X
MD225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Single Specialty