Provider Demographics
NPI:1144452749
Name:KIM, HEESOO KARINA (LCSW-R, PHD)
Entity type:Individual
Prefix:
First Name:HEESOO
Middle Name:KARINA
Last Name:KIM
Suffix:
Gender:F
Credentials:LCSW-R, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 N MAPLE AVENUE, #101
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07017
Mailing Address - Country:US
Mailing Address - Phone:917-447-8159
Mailing Address - Fax:917-447-8159
Practice Address - Street 1:36 WEST 25TH STREET, 10TH FLOOR
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010
Practice Address - Country:US
Practice Address - Phone:917-447-8159
Practice Address - Fax:917-447-8159
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR063025101YM0800X
NJ44SC05455900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00063025Medicaid