Provider Demographics
NPI:1104687979
Name:KIM, GRACE (PHD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 W. FOOTHILL BLVD SUITE C #517
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711
Mailing Address - Country:US
Mailing Address - Phone:626-593-6306
Mailing Address - Fax:
Practice Address - Street 1:150 E MEDA AVE STE 230
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-2624
Practice Address - Country:US
Practice Address - Phone:626-593-6306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18558103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical