Provider Demographics
NPI:1891973285
Name:LY, VY KIM
Entity Type:Individual
Prefix:
First Name:VY
Middle Name:KIM
Last Name:LY
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 1:310 8TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-6527
Mailing Address - Country:US
Mailing Address - Phone:510-451-6729
Mailing Address - Fax:
Practice Address - Street 1:310 8TH ST STE 201
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-6527
Practice Address - Country:US
Practice Address - Phone:510-451-6729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 101Y00000X
CA64302106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor