Provider Demographics
NPI:1346574159
Name:REBOUL, LILI YU LIM KIM (PSY D)
Entity type:Individual
Prefix:DR
First Name:LILI
Middle Name:YU LIM KIM
Last Name:REBOUL
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:DR
Other - First Name:LILI
Other - Middle Name:YU LIM
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:150 PAULARINO AVE STE C-100
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3301
Mailing Address - Country:US
Mailing Address - Phone:323-528-7644
Mailing Address - Fax:
Practice Address - Street 1:150 PAULARINO AVE STE C-100
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3301
Practice Address - Country:US
Practice Address - Phone:323-528-7644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 21450103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical