Provider Demographics
NPI:1972298875
Name:HANDEGARD, KIMBERLY A (QMHS, CM, GBM)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:HANDEGARD
Suffix:
Gender:F
Credentials:QMHS, CM, GBM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5563 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2225
Mailing Address - Country:US
Mailing Address - Phone:937-291-2300
Mailing Address - Fax:937-291-2303
Practice Address - Street 1:5563 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2225
Practice Address - Country:US
Practice Address - Phone:937-291-2300
Practice Address - Fax:937-291-2303
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0031785Medicaid