Provider Demographics
NPI:1851081061
Name:PARK-KIM, MIN JI
Entity Type:Individual
Prefix:
First Name:MIN JI
Middle Name:
Last Name:PARK-KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 BUENA VISTA LN
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-5624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24624 VAN ZANDT AVE
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-1239
Practice Address - Country:US
Practice Address - Phone:737-235-6277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00856101YM0800X
TX90026101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health