Provider Demographics
NPI:1104160910
Name:KIM, MIKE (PSYD)
Entity type:Individual
Prefix:DR
First Name:MIKE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 LOUISIANA BOULEVARD NORTHEAST
Mailing Address - Street 2:SUITE C1
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110
Mailing Address - Country:US
Mailing Address - Phone:505-884-7873
Mailing Address - Fax:
Practice Address - Street 1:2900 LOUISIANA BOULEVARD NORTHEAST
Practice Address - Street 2:SUITE C1
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-884-7873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0036103TP0016X
CAPSY21256103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist