Healthcare Provider Details

I. General information

NPI: 1114703337
Provider Name (Legal Business Name): KIMBERLY KINNEY LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2023
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4851 PASEO DEL SOL
SANTA FE NM
87507-3027
US

IV. Provider business mailing address

4730 BECKNER RD
SANTA FE NM
87507-3691
US

V. Phone/Fax

Practice location:
  • Phone: 505-467-1081
  • Fax:
Mailing address:
  • Phone: 505-467-1081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2023-0584
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: