Provider Demographics
NPI:1891290268
Name:KIE, KORY A
Entity Type:Individual
Prefix:
First Name:KORY
Middle Name:A
Last Name:KIE
Suffix:
Gender:M
Credentials:
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 640
Mailing Address - Street 2:
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022-0640
Mailing Address - Country:US
Mailing Address - Phone:505-869-3200
Mailing Address - Fax:505-869-4881
Practice Address - Street 1:1 SAGEBRUSH ST SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-3942
Practice Address - Country:US
Practice Address - Phone:505-869-3200
Practice Address - Fax:505-869-4881
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0194651101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)