Healthcare Provider Details

I. General information

NPI: 1487428843
Provider Name (Legal Business Name): KIMBERLY PINE DOUGHARTY LPAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 BECKNER RD
SANTA FE NM
87507-3691
US

IV. Provider business mailing address

1009 VELARDE RD
SANTA FE NM
87507-5126
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-4500
  • Fax: 505-443-8313
Mailing address:
  • Phone: 253-720-4871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberCTB20230922
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: