Provider Demographics
NPI:1700456746
Name:REYNOLDS, KIM STEPHAN (CPSW)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:STEPHAN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:CPSW
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 1846
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-1846
Mailing Address - Country:US
Mailing Address - Phone:575-758-2692
Mailing Address - Fax:575-751-5105
Practice Address - Street 1:501 PASEO DEL PUEBLO NORTE
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-758-2692
Practice Address - Fax:575-751-5105
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1295971505Medicaid