Provider Demographics
NPI:1013096551
Name:KIM, DANEIL IMKYU (PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:DANEIL
Middle Name:IMKYU
Last Name:KIM
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:DR
Other - First Name:DANIEL
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:12121 SHADOW RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-3826
Mailing Address - Country:US
Mailing Address - Phone:818-360-6902
Mailing Address - Fax:818-997-8743
Practice Address - Street 1:550 S VERMONT AVE FL 4
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1912
Practice Address - Country:US
Practice Address - Phone:818-351-7737
Practice Address - Fax:213-639-1361
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19028103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist