Provider Demographics
NPI:1497722417
Name:KIM, LISA ANN (MA, LISW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:KIM
Suffix:
Gender:F
Credentials:MA, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 WESTBURY DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245-2723
Mailing Address - Country:US
Mailing Address - Phone:319-356-6352
Mailing Address - Fax:319-358-2367
Practice Address - Street 1:673 WESTBURY DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-2723
Practice Address - Country:US
Practice Address - Phone:319-356-6352
Practice Address - Fax:319-358-2367
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAO56731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA225545000Medicaid