Provider Demographics
NPI:1134677917
Name:KIM, LORD J (LMSW)
Entity Type:Individual
Prefix:
First Name:LORD
Middle Name:J
Last Name:KIM
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RIVER PLACE DR STE 250
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-5402
Mailing Address - Country:US
Mailing Address - Phone:313-871-2337
Mailing Address - Fax:
Practice Address - Street 1:35 S JOHNSON ST STE 3C
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1662
Practice Address - Country:US
Practice Address - Phone:248-333-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010897661041C0700X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical