Provider Demographics
NPI:1215353081
Name:PULLIAM, KIM RENEE (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:RENEE
Last Name:PULLIAM
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 1:44 WATER ST
Mailing Address - Street 2:
Mailing Address - City:OWINGSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40360-8944
Mailing Address - Country:US
Mailing Address - Phone:606-674-9776
Mailing Address - Fax:606-674-9708
Practice Address - Street 1:44 WATER ST
Practice Address - Street 2:
Practice Address - City:OWINGSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40360-8944
Practice Address - Country:US
Practice Address - Phone:606-674-9776
Practice Address - Fax:606-674-9708
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100331190Medicaid
KYK067331Medicare PIN