Provider Demographics
NPI:1750117586
Name:KIM, CHRISTOPHER
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:KIM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:CHRIS
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1201 PORTO GRANDE UNIT 3
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-5414
Mailing Address - Country:US
Mailing Address - Phone:949-529-0234
Mailing Address - Fax:
Practice Address - Street 1:415 W ROUTE 66 STE 202
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4335
Practice Address - Country:US
Practice Address - Phone:626-963-4467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94028524103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical