Provider Demographics
NPI:1366173726
Name:KIM, SEOYOUNG
Entity type:Individual
Prefix:
First Name:SEOYOUNG
Middle Name:
Last Name:KIM
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 1:150 W SAINT CHARLES RD APT 227
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-2277
Mailing Address - Country:US
Mailing Address - Phone:501-749-4527
Mailing Address - Fax:
Practice Address - Street 1:1804 CENTRE POINT CIR STE 102
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-4849
Practice Address - Country:US
Practice Address - Phone:630-955-1940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XP0200X
IL056014498225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics