Basic Information
| Provider Information | |||||||||
| NPI: | 1811544935 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MFT ASSOCIATE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3208 ROSEMEAD BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917312830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262277001 | ||||||||
| FaxNumber: | 6262277015 | ||||||||
| Practice Location | |||||||||
| Address1: | 3208 ROSEMEAD BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917312830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262277001 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2019 | ||||||||
| LastUpdateDate: | 09/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 106H00000X | 120878 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.