Provider Demographics
NPI:1215634712
Name:KIM, MO SE
Entity type:Individual
Prefix:
First Name:MO
Middle Name:SE
Last Name:KIM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 N PARAMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-3711
Mailing Address - Country:US
Mailing Address - Phone:562-630-8672
Mailing Address - Fax:
Practice Address - Street 1:6930 BEACH BLVD UNIT L141
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-6856
Practice Address - Country:US
Practice Address - Phone:714-872-2291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5840101YM0800X
CA16606101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health