Provider Demographics
NPI:1770071680
Name:KIM, TIADORA (PSYD)
Entity type:Individual
Prefix:DR
First Name:TIADORA
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 1:15559 UNION AVE # 209
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-3904
Mailing Address - Country:US
Mailing Address - Phone:408-357-3680
Mailing Address - Fax:
Practice Address - Street 1:5755 COTTLE RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-3640
Practice Address - Country:US
Practice Address - Phone:408-972-3095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32830103T00000X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist