Provider Demographics
NPI:1891387916
Name:MCKIM, MICHELLE L
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:MCKIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:GRIMM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1701 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-6644
Mailing Address - Country:US
Mailing Address - Phone:701-751-0384
Mailing Address - Fax:888-901-7234
Practice Address - Street 1:1701 S 12TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-6644
Practice Address - Country:US
Practice Address - Phone:701-751-0384
Practice Address - Fax:888-901-7234
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional