Provider Demographics
NPI:1972197234
Name:SONG, KYUNGAE
Entity Type:Individual
Prefix:MRS
First Name:KYUNGAE
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KYUNG-AE
Other - Middle Name:
Other - Last Name:LONGBOTHAM SONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12021 9TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98177-4605
Mailing Address - Country:US
Mailing Address - Phone:206-679-2268
Mailing Address - Fax:
Practice Address - Street 1:12021 9TH AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98177-4605
Practice Address - Country:US
Practice Address - Phone:206-679-2268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC7790171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter