Provider Demographics
NPI:1114066404
Name:PRODGER, KIM (LCSW)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:PRODGER
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 1:4010 WATSON PLAZA DR
Mailing Address - Street 2:SUITE 285
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-4037
Mailing Address - Country:US
Mailing Address - Phone:562-497-1505
Mailing Address - Fax:562-497-1881
Practice Address - Street 1:4010 WATSON PLAZA DR
Practice Address - Street 2:SUITE 285
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-4037
Practice Address - Country:US
Practice Address - Phone:562-497-1505
Practice Address - Fax:562-497-1881
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 120461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical