Provider Demographics
NPI:1104220672
Name:PAYNE, KIMBERLY REID
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:REID
Last Name:PAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5203 JUAN TABO BLVD NE
Mailing Address - Street 2:STE 2A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2683
Mailing Address - Country:US
Mailing Address - Phone:505-933-6338
Mailing Address - Fax:505-221-5710
Practice Address - Street 1:5203 JUAN TABO BLVD NE
Practice Address - Street 2:STE 2A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2683
Practice Address - Country:US
Practice Address - Phone:505-933-6338
Practice Address - Fax:505-221-5710
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NM0193131101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health