Provider Demographics
NPI:1750857751
Name:KIM, SUSAN EUNJI (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:EUNJI
Last Name:KIM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11870 PIERCE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-5186
Mailing Address - Country:US
Mailing Address - Phone:951-248-4000
Mailing Address - Fax:
Practice Address - Street 1:11870 PIERCE ST STE 200
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-5186
Practice Address - Country:US
Practice Address - Phone:951-248-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA83283101YM0800X
CA114780101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health