Provider Demographics
NPI:1053943779
Name:KMR PSYCHIATRIC SERVICES LLC
Entity type:Organization
Organization Name:KMR PSYCHIATRIC SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, PMHNP
Authorized Official - Phone:260-610-3057
Mailing Address - Street 1:4656 W JEFFERSON BLVD STE 285
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6838
Mailing Address - Country:US
Mailing Address - Phone:260-422-9372
Mailing Address - Fax:
Practice Address - Street 1:4656 W JEFFERSON BLVD STE 285
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6838
Practice Address - Country:US
Practice Address - Phone:260-422-9372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-11
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201296650Medicaid