Provider Demographics
NPI:1689320731
Name:VISCAINO, KIMMBERLY (LBSW, LPN)
Entity Type:Individual
Prefix:MRS
First Name:KIMMBERLY
Middle Name:
Last Name:VISCAINO
Suffix:
Gender:F
Credentials:LBSW, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E. 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130
Mailing Address - Country:US
Mailing Address - Phone:575-356-7045
Mailing Address - Fax:575-359-0826
Practice Address - Street 1:700 E. 3RD ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6025
Practice Address - Country:US
Practice Address - Phone:575-356-7045
Practice Address - Fax:575-359-0826
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMB-110421041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty