Provider Demographics
NPI:1558455295
Name:TILL, KIM C (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:C
Last Name:TILL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:CATHERINE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 12404
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-8268
Mailing Address - Country:US
Mailing Address - Phone:949-643-6900
Mailing Address - Fax:
Practice Address - Street 1:5 MAREBLU
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3014
Practice Address - Country:US
Practice Address - Phone:949-643-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA277131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty