Provider Demographics
NPI:1811016041
Name:KIM, SU JUNG (LCSW)
Entity Type:Individual
Prefix:
First Name:SU
Middle Name:JUNG
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 1:550 S VERMONT AVE FL 10
Mailing Address - Street 2:OFFICE OF THE MEDICAL DIRECTOR, DEPT OF MENTAL HEALTH
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1912
Mailing Address - Country:US
Mailing Address - Phone:213-351-6033
Mailing Address - Fax:213-738-4646
Practice Address - Street 1:550 S VERMONT AVE FL 10
Practice Address - Street 2:OFFICE OF THE MEDICAL DIRECTOR, DEPT OF MENTAL HEALTH
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1912
Practice Address - Country:US
Practice Address - Phone:213-351-6033
Practice Address - Fax:213-738-4646
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW166741041C0700X
CALCS245101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS24510Medicare PIN