Provider Demographics
NPI:1659621415
Name:KIM, STELLA (PSYD)
Entity type:Individual
Prefix:
First Name:STELLA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 CONCORD ST APT 105
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2817
Mailing Address - Country:US
Mailing Address - Phone:562-858-7887
Mailing Address - Fax:
Practice Address - Street 1:8616 LA TIJERA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3945
Practice Address - Country:US
Practice Address - Phone:310-337-1550
Practice Address - Fax:800-549-4717
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94024164103TC0700X
225400000X, 390200000X
CA35000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program