Provider Demographics
NPI:1770576175
Name:HALBACK, KIM (LICSW)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:HALBACK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4006 BISHOPMILL DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3405
Mailing Address - Country:US
Mailing Address - Phone:202-290-8335
Mailing Address - Fax:866-936-0235
Practice Address - Street 1:3311 TOLEDO TER STE B103
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-8146
Practice Address - Country:US
Practice Address - Phone:800-431-6377
Practice Address - Fax:866-936-0235
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2023-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6651104100000X
DCLC500785151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC372048Medicaid
SC7124Medicare ID - Type Unspecified
SC372048Medicaid