Provider Demographics
NPI:1841525565
Name:KIM, STACEY (LSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N JORDAN AVE
Mailing Address - Street 2:INDIANA UNIVERSITY COUNSELING AND PSYCHOLOGICAL SERVICE
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-3190
Mailing Address - Country:US
Mailing Address - Phone:812-855-5711
Mailing Address - Fax:812-855-8447
Practice Address - Street 1:600 N JORDAN AVE
Practice Address - Street 2:INDIANA UNIVERSITY COUNSELING AND PSYCHOLOGICAL SERVICE
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3190
Practice Address - Country:US
Practice Address - Phone:812-855-5711
Practice Address - Fax:812-855-8447
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33005674A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker