Provider Demographics
NPI:1538894431
Name:KIM, TAMMY
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:KIM
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 1:17 MOUNTAINVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ARDSLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10502-1903
Mailing Address - Country:US
Mailing Address - Phone:908-253-2994
Mailing Address - Fax:
Practice Address - Street 1:6700 KIRKVILLE ROAD
Practice Address - Street 2:BUILDING B, SUITE 103B
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057
Practice Address - Country:US
Practice Address - Phone:315-492-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-24
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114371-01106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist