Provider Demographics
NPI:1609097203
Name:BOUBON, KIM L (LCSW)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:L
Last Name:BOUBON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9319 BELLEGARDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277
Mailing Address - Country:US
Mailing Address - Phone:704-341-1226
Mailing Address - Fax:
Practice Address - Street 1:13850 BALLANTYNE CORPORATE PLACE
Practice Address - Street 2:SUITE #500
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-341-1226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0047401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002946Medicaid
NC2879103AMedicare ID - Type UnspecifiedPROVIDER# GP#2347125