Provider Demographics
NPI:1386199461
Name:KIM E. LUCEY LCSW
Entity Type:Organization
Organization Name:KIM E. LUCEY LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:E
Authorized Official - Last Name:LUCEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:971-225-0105
Mailing Address - Street 1:1020 SW TAYLOR ST STE 700
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2512
Mailing Address - Country:US
Mailing Address - Phone:971-225-0105
Mailing Address - Fax:
Practice Address - Street 1:1020 SW TAYLOR ST STE 700
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2512
Practice Address - Country:US
Practice Address - Phone:971-225-0105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL36761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500653429Medicaid