Provider Demographics
NPI:1699916486
Name:HYDE, KELLY L (PHD, LPCC, CHT, BCPC)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:HYDE
Suffix:
Gender:F
Credentials:PHD, LPCC, CHT, BCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 LLANO ST STE B142
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5415
Mailing Address - Country:US
Mailing Address - Phone:505-908-0706
Mailing Address - Fax:
Practice Address - Street 1:1704 LLANO ST STE B142
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5415
Practice Address - Country:US
Practice Address - Phone:505-908-0706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0186911101YP2500X
NM0104471103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM73725773Medicaid