Provider Demographics
NPI:1902106024
Name:KIM, MINSOO (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:MINSOO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7925 WINCHESTER BLVD BLDG 40
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2128
Mailing Address - Country:US
Mailing Address - Phone:718-464-7500
Mailing Address - Fax:
Practice Address - Street 1:7925 WINCHESTER BLVD BLDG 40
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-2128
Practice Address - Country:US
Practice Address - Phone:718-464-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY082555-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical