Provider Demographics
NPI:1023730793
Name:LIM, MI JOUNG
Entity type:Individual
Prefix:
First Name:MI JOUNG
Middle Name:
Last Name:LIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 GLEN HOLLOW DR APT B35
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-2448
Mailing Address - Country:US
Mailing Address - Phone:631-880-8182
Mailing Address - Fax:
Practice Address - Street 1:7 GLEN HOLLOW DR APT B35
Practice Address - Street 2:
Practice Address - City:HOLTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11742-2448
Practice Address - Country:US
Practice Address - Phone:631-880-8182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY413187163WP0807X
NY493929-1163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY637770470Medicaid