Provider Demographics
NPI:1235588674
Name:KIBUTA, SHAWNA AVILA (MS, LMHC)
Entity Type:Individual
Prefix:MS
First Name:SHAWNA
Middle Name:AVILA
Last Name:KIBUTA
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:
Other - Last Name:STIGGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8205 SPAIN RD NE STE 106
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3155
Mailing Address - Country:US
Mailing Address - Phone:505-856-0300
Mailing Address - Fax:505-856-7946
Practice Address - Street 1:8205 SPAIN RD NE STE 106
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3155
Practice Address - Country:US
Practice Address - Phone:505-856-0300
Practice Address - Fax:505-856-7946
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NMCTL0202841101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN3938Medicaid