Provider Demographics
NPI:1457035727
Name:LUTZ KIM, VICTORIA AILEEN
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:AILEEN
Last Name:LUTZ KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:AILEEN
Other - Last Name:LUTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:941 CRESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3019
Mailing Address - Country:US
Mailing Address - Phone:773-844-0152
Mailing Address - Fax:
Practice Address - Street 1:2440 RAVINE WAY STE 600
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7647
Practice Address - Country:US
Practice Address - Phone:847-730-3042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490083411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical