Basic Information
| Provider Information | |||||||||
| NPI: | 1417990466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 91-2301 FORT WEAVER RD | ||||||||
| Address2: | |||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967063602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086718511 | ||||||||
| FaxNumber: | 8086768035 | ||||||||
| Practice Location | |||||||||
| Address1: | 91-2301 FORT WEAVER RD | ||||||||
| Address2: | |||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967063602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086718511 | ||||||||
| FaxNumber: | 8086768035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 02/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-3089 | HI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 55482501 | 01 | HI | ALOHACARE | OTHER | 0000248385 | 01 | HI | HMSA | OTHER | 788861 | 01 | HI | UNIVERSITY HEALTH ALLIANC | OTHER | 990298651-96706-C002 | 01 | HI | TRICARE | OTHER | 554825 | 05 | HI | MEDICAID |