Provider Demographics
NPI:1720411473
Name:KIM, SHANNA YONG (MA, MS, PHD)
Entity Type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:YONG
Last Name:KIM
Suffix:
Gender:F
Credentials:MA, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 LEESE ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-5827
Mailing Address - Country:US
Mailing Address - Phone:408-891-1435
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVE # 7G26
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:628-206-8426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 101Y00000X, 390200000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program