Provider Demographics
NPI:1043500200
Name:HART, KIM LEE (LCADC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:LEE
Last Name:HART
Suffix:
Gender:F
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 HWY 71 STE 3C
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-3278
Mailing Address - Country:US
Mailing Address - Phone:732-556-6290
Mailing Address - Fax:732-556-6015
Practice Address - Street 1:1901 HWY 71 STE 3C
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-3278
Practice Address - Country:US
Practice Address - Phone:732-556-6290
Practice Address - Fax:732-556-6015
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-08
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00173200101YM0800X
NJ37PC00459300101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health