Provider Demographics
NPI:1801164850
Name:KIM, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 ROCK GLEN AVE
Mailing Address - Street 2:STE 311
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-2056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1151 W 6TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1828
Practice Address - Country:US
Practice Address - Phone:213-639-2579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist