Provider Demographics
NPI:1972841054
Name:LUCEY, KIM E (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:E
Last Name:LUCEY
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 1:1020 SW TAYLOR ST STE 700
Mailing Address - Street 2:1125
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2512
Mailing Address - Country:US
Mailing Address - Phone:971-225-0105
Mailing Address - Fax:
Practice Address - Street 1:1020 SW TAYLOR ST STE 700
Practice Address - Street 2:1125
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2512
Practice Address - Country:US
Practice Address - Phone:971-225-0105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL36761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500653429Medicaid