Provider Demographics
NPI:1942758461
Name:HAYNIE, KIMBERLY ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:HAYNIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W APACHE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-3886
Mailing Address - Country:US
Mailing Address - Phone:505-258-2763
Mailing Address - Fax:505-675-2803
Practice Address - Street 1:1200 W APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-3886
Practice Address - Country:US
Practice Address - Phone:505-258-2763
Practice Address - Fax:505-675-2803
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-118101041C0700X
NM107307494101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM61224502Medicaid
NM107307494OtherNEW MEXICO DRIVERS LICENSE
NM61224502Medicaid