MEDICARE: DUSTIN RAYMOND MCKIMMY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	6451023857	MI

General Provider Information

NPI Number	:	1942027412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTIN RAYMOND MCKIMMY LLC

Provider Business Mailing Address
First Line	:	6720 LANSDOWN DR
Second Line	:
City	:	DIMONDALE
State	:	MI
Zip	:	48821-9430
Country	:	US
Telephone Number	:	517-899-0572
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 W LAKE LANSING RD STE B110
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48823-8468
Country	:	US
Telephone Number	:	517-657-3533
Fax Number	:	517-580-0530

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2024
Last Update Date	:	09/25/2024

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