Provider Demographics
NPI:1750692505
Name:KIM, KELLY KYUNGHEE
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:KYUNGHEE
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3237 34TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-1801
Mailing Address - Country:US
Mailing Address - Phone:917-696-8028
Mailing Address - Fax:
Practice Address - Street 1:3237 34TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-1801
Practice Address - Country:US
Practice Address - Phone:917-696-8028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-27
Last Update Date:2015-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012374-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist