Provider Demographics
NPI:1578134425
Name:KIM, JOHNNY (LCSW)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6036 WESTMINSTER PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-1412
Mailing Address - Country:US
Mailing Address - Phone:214-551-0909
Mailing Address - Fax:
Practice Address - Street 1:677 CRAIG RD STE 214
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7125
Practice Address - Country:US
Practice Address - Phone:314-669-1305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.028195101YM0800X
101YM0800X
MO2023038331101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health