Provider Demographics
NPI:1669758322
Name:KIM, MICHAEL JEFFREY (LPSYA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEFFREY
Last Name:KIM
Suffix:
Gender:M
Credentials:LPSYA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 W 47TH ST APT 4RE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-2442
Mailing Address - Country:US
Mailing Address - Phone:917-202-7261
Mailing Address - Fax:
Practice Address - Street 1:3016 31ST ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-2269
Practice Address - Country:US
Practice Address - Phone:917-202-7261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000819102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst