Provider Demographics
NPI:1932861028
Name:KIM, MICHELLE JIHAE (DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JIHAE
Last Name:KIM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 W WILSON ST STE 202
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1586
Mailing Address - Country:US
Mailing Address - Phone:949-631-0125
Mailing Address - Fax:949-631-0127
Practice Address - Street 1:15771 ROCKFIELD BLVD STE 150
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2846
Practice Address - Country:US
Practice Address - Phone:949-750-8499
Practice Address - Fax:949-446-6294
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT300550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist