Provider Demographics
NPI:1699191494
Name:KIM, MINAH (MT)
Entity Type:Individual
Prefix:
First Name:MINAH
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5043 AUBURN WAY S
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98092-7205
Mailing Address - Country:US
Mailing Address - Phone:360-292-7245
Mailing Address - Fax:360-292-7246
Practice Address - Street 1:5322 ORCHARD ST W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98467-3633
Practice Address - Country:US
Practice Address - Phone:253-476-3333
Practice Address - Fax:253-476-3334
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60422590225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist