Provider Demographics
NPI:1083833453
Name:KIM, CAROLYN GRACE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:GRACE
Last Name:KIM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36141 AVENUE 12
Mailing Address - Street 2:#109
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638-8712
Mailing Address - Country:US
Mailing Address - Phone:559-645-8802
Mailing Address - Fax:
Practice Address - Street 1:36141 AVENUE 12
Practice Address - Street 2:#109
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-8712
Practice Address - Country:US
Practice Address - Phone:559-645-8802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA180801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical