Provider Demographics
NPI:1356196281
Name:KIM, MICHELE (CPED)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 BERGEN BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-2116
Mailing Address - Country:US
Mailing Address - Phone:201-328-2776
Mailing Address - Fax:
Practice Address - Street 1:1402 BERGEN BLVD
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-2116
Practice Address - Country:US
Practice Address - Phone:201-328-2776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJCPED4638224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist