Healthcare Provider Details

I. General information

NPI: 1558455295
Provider Name (Legal Business Name): KIM C. TILL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIM CATHERINE SMITH LCSW

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MAREBLU
ALISO VIEJO CA
92656-3014
US

IV. Provider business mailing address

PO BOX 12404
COSTA MESA CA
92627-8268
US

V. Phone/Fax

Practice location:
  • Phone: 949-643-6900
  • Fax:
Mailing address:
  • Phone: 949-643-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number27713
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: