Provider Demographics
NPI:1881996551
Name:KIM, VIRGIL
Entity type:Individual
Prefix:
First Name:VIRGIL
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DONG WAN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14090 FRYELANDS BLVD SE STE 347
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-2760
Mailing Address - Country:US
Mailing Address - Phone:360-805-3122
Mailing Address - Fax:360-805-9180
Practice Address - Street 1:14090 FRYELANDS BLVD SE STE 347
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2760
Practice Address - Country:US
Practice Address - Phone:360-805-3122
Practice Address - Fax:360-805-9180
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60795326101YA0400X
WAMG60172608106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1881996551Medicaid