Basic Information
| Provider Information | |||||||||
| NPI: | 1134677917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | LORD | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 RIVER PLACE DR STE 250 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482075402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138712337 | ||||||||
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| Practice Location | |||||||||
| Address1: | 35 S JOHNSON ST STE 3C | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483411662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483337222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2016 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801089766 | MI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 6801089766 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.