Provider Demographics
NPI:1811378334
Name:KIM, TATE (MFT - INTERN)
Entity Type:Individual
Prefix:
First Name:TATE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MFT - INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15400 SHERMAN WAY STE 220
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-7403
Mailing Address - Country:US
Mailing Address - Phone:818-267-1100
Mailing Address - Fax:818-267-1199
Practice Address - Street 1:15400 SHERMAN WAY STE 220
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-7403
Practice Address - Country:US
Practice Address - Phone:818-267-1100
Practice Address - Fax:818-267-1199
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT94009106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist