Provider Demographics
NPI:1790012318
Name:KIM, GRACE Y (PHD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:Y
Last Name:KIM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 NICOLLET MALL
Mailing Address - Street 2:SUITE 1455
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-2606
Mailing Address - Country:US
Mailing Address - Phone:612-345-5194
Mailing Address - Fax:612-354-7974
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:SUITE 415
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2606
Practice Address - Country:US
Practice Address - Phone:612-345-5194
Practice Address - Fax:612-354-7974
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5726103T00000X
DCPSY1000525103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist