Provider Demographics
NPI:1063904134
Name:KIM, JUSTIN (MDPP COACH)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MDPP COACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BROAD AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650
Mailing Address - Country:US
Mailing Address - Phone:201-313-0131
Mailing Address - Fax:
Practice Address - Street 1:7 BROAD AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650
Practice Address - Country:US
Practice Address - Phone:201-313-0131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional