Provider Demographics
NPI:1972116440
Name:KIM, HEIDI (LCSW)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:KIM
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 1:11712 MOORPARK ST STE 105
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2156
Mailing Address - Country:US
Mailing Address - Phone:818-900-5152
Mailing Address - Fax:
Practice Address - Street 1:11712 MOORPARK ST STE 105
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2156
Practice Address - Country:US
Practice Address - Phone:818-900-5152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1212571041C0700X
390200000X
CA102253101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program