Healthcare Provider Details

I. General information

NPI: 1417020173
Provider Name (Legal Business Name): KIM K LONGBOTTOM LCSW, LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 OLEANDER DR STE 202A
WILMINGTON NC
28403-6846
US

IV. Provider business mailing address

4000 OLEANDER DR STE 202A
WILMINGTON NC
28403-6846
US

V. Phone/Fax

Practice location:
  • Phone: 910-791-5171
  • Fax: 910-781-5777
Mailing address:
  • Phone: 910-791-5171
  • Fax: 910-781-5777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC0044309
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1085
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: