Provider Demographics
NPI:1831362235
Name:ST LAURENCE, KYUNG
Entity type:Individual
Prefix:
First Name:KYUNG
Middle Name:
Last Name:ST LAURENCE
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 1:4408 MAYAPAN DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-7144
Mailing Address - Country:US
Mailing Address - Phone:415-885-9793
Mailing Address - Fax:
Practice Address - Street 1:4408 MAYAPAN DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7144
Practice Address - Country:US
Practice Address - Phone:415-885-9793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50180106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSB94026418OtherREGISTERED PSYCHOLOGICAL ASSISTANT
CALMFT50180OtherLICENSED MARRIAGE AND FAMILY THERAPIST