Provider Demographics
NPI:1831325828
Name:BYRNE, KIMBERLY SHANNON (LCSW, LADAC)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:SHANNON
Last Name:BYRNE
Suffix:
Gender:F
Credentials:LCSW, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N PENNSYLVANIA AVE STE 670C
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4755
Mailing Address - Country:US
Mailing Address - Phone:575-623-7336
Mailing Address - Fax:
Practice Address - Street 1:400 N PENNSYLVANIA AVE STE 670C
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4755
Practice Address - Country:US
Practice Address - Phone:575-623-7336
Practice Address - Fax:575-623-7337
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0086251101YA0400X
NMI-073451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)