Healthcare Provider Details

I. General information

NPI: 1700126794
Provider Name (Legal Business Name): KIM CANTRELL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 SOUTHERN BLVD SE STE 203C
RIO RANCHO NM
87124-3758
US

IV. Provider business mailing address

8205 SPAIN RD NE SUITE 106
ALBUQUERQUE NM
87109-3179
US

V. Phone/Fax

Practice location:
  • Phone: 505-362-3515
  • Fax:
Mailing address:
  • Phone: 505-362-3515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06910
License Number StateNM

VIII. Authorized Official

Name: KIM CANTRELL
Title or Position: OWNER
Credential: LISW
Phone: 505-362-3515