Provider Demographics
NPI:1063994721
Name:KIM, KWANG IL (MSW)
Entity type:Individual
Prefix:MR
First Name:KWANG
Middle Name:IL
Last Name:KIM
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1866
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-1866
Mailing Address - Country:US
Mailing Address - Phone:503-432-0333
Mailing Address - Fax:
Practice Address - Street 1:322 NW 5TH AVE STE 301B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3828
Practice Address - Country:US
Practice Address - Phone:503-432-0333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA2995101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORA2995OtherOREGON BOARD OF LICENSED SOCIAL WORKERS