MEDICARE: KMB MENTAL HEALTH SERVICES 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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1629830344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KMB MENTAL HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	278 CEDAR LN SE # 4104
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22180-6613
Country	:	US
Telephone Number	:	703-278-3767
Fax Number	:

Provider Business Practice Location Address
First Line	:	278 CEDAR LN SE # 4104
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22180-6613
Country	:	US
Telephone Number	:	703-278-3767
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KATARINA MIJIC-BARISIC
Credential	:	PMHNP-BC
Telephone Number	:	216-924-8879

Provider Enumeration Date	:	01/29/2024
Last Update Date	:	01/29/2024

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