MEDICARE: DAVID A KININGHAM M.ED

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	39001795A	IN

General Provider Information

NPI Number	:	1215025853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID A KININGHAM M.ED

Provider Business Mailing Address
First Line	:	6334 CONSTITUTION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1518
Country	:	US
Telephone Number	:	260-209-1209
Fax Number	:	260-782-3215

Provider Business Practice Location Address
First Line	:	6334 CONSTITUTION DR.
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-4680
Country	:	US
Telephone Number	:	260-260-1209
Fax Number	:	260-782-3215

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

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	02/21/2020

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