Provider Demographics
NPI:1740562941
Name:KIM, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
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 1:11038 HIGHLAND BLVD STE 475
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3785
Mailing Address - Country:US
Mailing Address - Phone:857-264-0418
Mailing Address - Fax:
Practice Address - Street 1:11038 HIGHLAND BLVD STE 475
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-3785
Practice Address - Country:US
Practice Address - Phone:857-264-0418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
UT94525633902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist