Provider Demographics
NPI:1831665579
Name:KIM, SANGMOON (PHD)
Entity Type:Individual
Prefix:
First Name:SANGMOON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 SARASOTA AVE
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-3016
Mailing Address - Country:US
Mailing Address - Phone:607-239-7735
Mailing Address - Fax:
Practice Address - Street 1:32 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ENDWELL
Practice Address - State:NY
Practice Address - Zip Code:13760-1062
Practice Address - Country:US
Practice Address - Phone:607-757-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-21
Last Update Date:2018-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020399103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist