Healthcare Provider Details

I. General information

NPI: 1003035411
Provider Name (Legal Business Name): KIM M SERVENT LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601A SAINT MICHAELS DR
SANTA FE NM
87505-7614
US

IV. Provider business mailing address

452 ACEQUIA MADRE APT 2
SANTA FE NM
87505-2311
US

V. Phone/Fax

Practice location:
  • Phone: 505-954-8786
  • Fax: 505-954-8794
Mailing address:
  • Phone: 505-989-5012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0094661
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: