Provider Demographics
NPI:1235238197
Name:MCKIM, LOIS HIEMSTRA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LOIS
Middle Name:HIEMSTRA
Last Name:MCKIM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:LOIS
Other - Middle Name:ANN
Other - Last Name:HIEMSTRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1450 SACHEM PLACE
Mailing Address - Street 2:UNIT 101
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22932-2227
Mailing Address - Country:US
Mailing Address - Phone:434-973-5640
Mailing Address - Fax:434-973-0290
Practice Address - Street 1:1450 SACHEM PLACE
Practice Address - Street 2:UNIT 101
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22932-2227
Practice Address - Country:US
Practice Address - Phone:434-973-5640
Practice Address - Fax:434-973-0290
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040016031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0904001603OtherTRICARE PRIME
VA8907251Medicaid
C9408010260OtherANTHEM