Provider Demographics
NPI:1780183731
Name:KIM, MI HAE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MI HAE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 S 4TH ST # 3F
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-3125
Mailing Address - Country:US
Mailing Address - Phone:562-714-5857
Mailing Address - Fax:
Practice Address - Street 1:2501B REED ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-3900
Practice Address - Country:US
Practice Address - Phone:215-568-2435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA103TS0200X
PAPS018279103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool