Provider Demographics
NPI:1174901631
Name:SHIM, GINA (BCBA)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:SHIM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:206 N JACKSON ST STE 202
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4330
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:818-241-6853
Practice Address - Street 1:741 GLENVIA ST STE 200
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-2425
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:818-241-6853
Is Sole Proprietor?:No
Enumeration Date:2015-05-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-15-18158103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst