Provider Demographics
NPI:1467521815
Name:DONALDSON, KLYNN DAVID (LISW)
Entity Type:Individual
Prefix:MR
First Name:KLYNN
Middle Name:DAVID
Last Name:DONALDSON
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6036
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88006-6036
Mailing Address - Country:US
Mailing Address - Phone:505-373-5057
Mailing Address - Fax:505-373-5058
Practice Address - Street 1:3521 DEL REY BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-7708
Practice Address - Country:US
Practice Address - Phone:505-373-5057
Practice Address - Fax:505-373-5058
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-048121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM100802OtherVALUE OPTIONS NEW MEXICO
NM01187520Medicaid