Basic Information
| Provider Information | |||||||||
| NPI: | 1255786422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | GINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21141 CANADA RD | ||||||||
| Address2: | APT 2A | ||||||||
| City: | LAKE FOREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926302754 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 23361 MADERO | ||||||||
| Address2: | STE #150 | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926912715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495818239 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2016 | ||||||||
| LastUpdateDate: | 04/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 10557 | CA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.