Provider Demographics
NPI:1003223033
Name:SO, MINKYUNG
Entity type:Individual
Prefix:
First Name:MINKYUNG
Middle Name:
Last Name:SO
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 1:560 W MAIN ST STE C229
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-3374
Mailing Address - Country:US
Mailing Address - Phone:310-853-8211
Mailing Address - Fax:
Practice Address - Street 1:1849 SAWTELLE BLVD STE 610
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7013
Practice Address - Country:US
Practice Address - Phone:310-853-8211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80802106H00000X
CA103011106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist