Provider Demographics
NPI:1962530790
Name:IM, NAKYUNG (LICSW,,LADC1,IABMCP)
Entity type:Individual
Prefix:MISS
First Name:NAKYUNG
Middle Name:
Last Name:IM
Suffix:
Gender:F
Credentials:LICSW,,LADC1,IABMCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308A HARVARD ST
Mailing Address - Street 2:#2
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-2900
Mailing Address - Country:US
Mailing Address - Phone:617-738-9622
Mailing Address - Fax:617-738-9623
Practice Address - Street 1:308A HARVARD ST
Practice Address - Street 2:#2
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-2900
Practice Address - Country:US
Practice Address - Phone:617-738-9622
Practice Address - Fax:617-738-9623
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1031151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA012700OtherVALUEOPTIONS
MA1858572Medicaid
MA239881OtherPRIVATE HEALTH CARE SYSTE
MAS024286OtherCHAMPUS
MA724940OtherTUFTS HEALTH PLAN
MA1898256Medicaid
MA249058OtherTRICARE
MA62-03541OtherUNITED BEHAVIOR HEALTH
MA724940OtherSECURE HORIZON
MA2040351OtherCIGNA HEALTH
MA4504465OtherAETNA HEALTH CARE
MAP03698OtherBLUECROSSBLUESHIELD
MA831200OtherFIRST HEALTH GROUP CORP.
MA1898256Medicaid