Provider Demographics
NPI:1285824573
Name:IESE, KIMBERLY JD (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JD
Last Name:IESE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:J
Other - Last Name:DEFENBAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:500 ALA MOANA BLVD STE 6D
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-4984
Mailing Address - Country:US
Mailing Address - Phone:808-777-4000
Mailing Address - Fax:808-447-0571
Practice Address - Street 1:500 ALA MOANA BLVD STE 6D
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-4984
Practice Address - Country:US
Practice Address - Phone:808-777-4000
Practice Address - Fax:808-447-0571
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7339-1231041C0700X
HI36441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43720500Medicaid