Provider Demographics
NPI:1366780454
Name:MEYER, KIM A (PHD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:A
Last Name:MEYER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6619 HIGH RIDGE PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-8174
Mailing Address - Country:US
Mailing Address - Phone:505-206-1816
Mailing Address - Fax:
Practice Address - Street 1:6619 HIGH RIDGE PL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-8174
Practice Address - Country:US
Practice Address - Phone:505-206-1816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1262103TC0700X
HI941103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39057534Medicaid
NM39057534Medicaid