MEDICARE: KMK FAMILY SERVICES, INC

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	6521299-6004	UT

General Provider Information

NPI Number	:	1184127144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KMK FAMILY SERVICES, INC

Provider Business Mailing Address
First Line	:	PO BOX 17864
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-0864
Country	:	US
Telephone Number	:	801-201-7050
Fax Number	:	801-274-0411

Provider Business Practice Location Address
First Line	:	5620 S WATERBURY WAY STE A206
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-6206
Country	:	US
Telephone Number	:	801-201-7050
Fax Number	:	801-274-0411

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KATHLEEN KALOUDIS
Credential	:	CMHC
Telephone Number	:	801-201-7050

Provider Enumeration Date	:	03/15/2018
Last Update Date	:	03/15/2018

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