Provider Demographics
NPI:1417990466
Name:KIM, JOHN B (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:B
Last Name:KIM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-2301 FORT WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3602
Mailing Address - Country:US
Mailing Address - Phone:808-671-8511
Mailing Address - Fax:808-676-8035
Practice Address - Street 1:91-2301 FORT WEAVER RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-3602
Practice Address - Country:US
Practice Address - Phone:808-671-8511
Practice Address - Fax:808-676-8035
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILCSW-30891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI55482501OtherALOHACARE
HI0000248385OtherHMSA
HI788861OtherUNIVERSITY HEALTH ALLIANC
HI990298651-96706-C002OtherTRICARE
HI554825Medicaid
HI554825Medicaid
HI788861OtherUNIVERSITY HEALTH ALLIANC