Provider Demographics
NPI:1861612863
Name:KIM, MIJIN (LCAT)
Entity type:Individual
Prefix:DR
First Name:MIJIN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3446 CRESCENT ST FL 1.
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-3918
Mailing Address - Country:US
Mailing Address - Phone:917-767-5237
Mailing Address - Fax:718-519-4240
Practice Address - Street 1:98 RIVERSIDE DR STE 1A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-5323
Practice Address - Country:US
Practice Address - Phone:917-767-5237
Practice Address - Fax:718-519-4240
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000514225A00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist