Provider Demographics
NPI:1710649348
Name:KIM, CRYSTAL SOO-OH
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:SOO-OH
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:S
Other - Last Name:OH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1101 DOVE ST STE 255
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2819
Mailing Address - Country:US
Mailing Address - Phone:949-216-4711
Mailing Address - Fax:
Practice Address - Street 1:1101 DOVE ST STE 255
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2819
Practice Address - Country:US
Practice Address - Phone:949-216-4711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical