Provider Demographics
NPI:1356660609
Name:WYMAN BRYANT, KIMBERLY N (BMS)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:WYMAN BRYANT
Suffix:
Gender:F
Credentials:BMS
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:WYMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 W 21ST STREET
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:575-769-2345
Mailing Address - Fax:575-769-9013
Practice Address - Street 1:1100 W 21ST STREET
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-769-2345
Practice Address - Fax:575-769-9013
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NMCTB-2022-0932101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM69732299Medicaid