Provider Demographics
NPI:1932264454
Name:KIM, MICHELLE M (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:M
Last Name:KIM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3936 DONNA DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-2439
Mailing Address - Country:US
Mailing Address - Phone:215-938-0776
Mailing Address - Fax:
Practice Address - Street 1:6200 FRANKFORD AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19135-3405
Practice Address - Country:US
Practice Address - Phone:215-535-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015005103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP50963Medicare UPIN
PA055026Medicare ID - Type Unspecified