Provider Demographics
NPI:1568428779
Name:HAMSTRA, KIM J (MA LPCC)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:J
Last Name:HAMSTRA
Suffix:
Gender:F
Credentials:MA LPCC
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 228
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571
Mailing Address - Country:US
Mailing Address - Phone:505-770-0439
Mailing Address - Fax:505-758-3598
Practice Address - Street 1:413 SIPAPU ROAD
Practice Address - Street 2:BOX 6952
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:505-758-5857
Practice Address - Fax:505-758-2832
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0088421101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29550009Medicaid