Provider Demographics
NPI:1275812281
Name:KIM, SEON W (PHD)
Entity type:Individual
Prefix:DR
First Name:SEON
Middle Name:W
Last Name:KIM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7-8 FOREST GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-6650
Mailing Address - Country:US
Mailing Address - Phone:718-350-6711
Mailing Address - Fax:
Practice Address - Street 1:24 SYCAMORE LN
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-4537
Practice Address - Country:US
Practice Address - Phone:718-350-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1583106H00000X
VA0717002021106H00000X
FLTPMF880106H00000X
WALF61417660106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist