Basic Information
| Provider Information | |||||||||
| NPI: | 1396124707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | MYEONG JIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 475 48TH AVE APT 219 | ||||||||
| Address2: | |||||||||
| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111095503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175041606 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1745 BROADWAY FL 17 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100194642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128518102 | ||||||||
| FaxNumber: | 2125370102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2015 | ||||||||
| LastUpdateDate: | 09/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 021616 | NY | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 021616 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.