Provider Demographics
NPI:1275417412
Name:KIM, MYUNGHWAN
Entity type:Individual
Prefix:
First Name:MYUNGHWAN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 ALEXANDER SPRINGS LN APT 18
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4024
Mailing Address - Country:US
Mailing Address - Phone:984-239-7490
Mailing Address - Fax:
Practice Address - Street 1:3331 HERITAGE TRADE DR STE 110
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-4346
Practice Address - Country:US
Practice Address - Phone:919-594-1879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-01
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician