Provider Demographics
NPI:1861753782
Name:KIM, SHELLY (MS ED)
Entity type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14714 84TH RD
Mailing Address - Street 2:APT 5E
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2243
Mailing Address - Country:US
Mailing Address - Phone:347-675-5475
Mailing Address - Fax:
Practice Address - Street 1:14714 84TH RD
Practice Address - Street 2:APT 5E
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435-2243
Practice Address - Country:US
Practice Address - Phone:347-675-5475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist