Provider Demographics
NPI:1801269857
Name:KMDT SERVICES LLC
Entity type:Organization
Organization Name:KMDT SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHARINE
Authorized Official - Middle Name:HELENE
Authorized Official - Last Name:MCHUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:571-279-8144
Mailing Address - Street 1:7937 FLAGER CIR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-7437
Mailing Address - Country:US
Mailing Address - Phone:571-279-8144
Mailing Address - Fax:
Practice Address - Street 1:8420 DORSEY CIR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-8300
Practice Address - Country:US
Practice Address - Phone:571-279-8144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904007119251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945247Medicaid
020063P10OtherMEDICARE NUMBER