Provider Demographics
NPI:1780102285
Name:MAESTAS, KATHIE D (LMHC)
Entity type:Individual
Prefix:
First Name:KATHIE
Middle Name:D
Last Name:MAESTAS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:KATHIE
Other - Middle Name:
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 W 21ST ST
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 ST
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:2017-09-05
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCMH0191741101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18055869Medicaid