Provider Demographics
NPI:1689050809
Name:KIM, AMANDA (PSYD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 BROOKHOLLOW DR STE 212
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5411
Mailing Address - Country:US
Mailing Address - Phone:714-386-9171
Mailing Address - Fax:
Practice Address - Street 1:1560 BROOKHOLLOW DR STE 212
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5411
Practice Address - Country:US
Practice Address - Phone:714-386-9171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33503103TA0400X, 103TF0000X, 103TP2701X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy