Provider Demographics
NPI:1780911404
Name:THIESSEN, KIM (LCSW)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:THIESSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-1103
Mailing Address - Country:US
Mailing Address - Phone:201-795-8683
Mailing Address - Fax:
Practice Address - Street 1:179 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1103
Practice Address - Country:US
Practice Address - Phone:201-795-8375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055852001041C0700X
NY081313-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0468312Medicaid
NY00079632Medicaid