Provider Demographics
NPI:1124335856
Name:SHIM, DAVID JUNG SUG (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JUNG SUG
Last Name:SHIM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:J
Other - Last Name:GEHRENBECK-SHIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:11 BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-7003
Mailing Address - Country:US
Mailing Address - Phone:781-893-0611
Mailing Address - Fax:
Practice Address - Street 1:1507 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEST NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02465-2219
Practice Address - Country:US
Practice Address - Phone:781-985-5745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7738103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical