MEDICARE: KMS MENTAL HEALTH AND WELLNESS

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1679228233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KMS MENTAL HEALTH AND WELLNESS

Provider Business Mailing Address
First Line	:	55097 FALLBROOKE DR
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-1852
Country	:	US
Telephone Number	:	248-854-8659
Fax Number	:

Provider Business Practice Location Address
First Line	:	1109 W LONG LAKE RD
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-1967
Country	:	US
Telephone Number	:	248-854-8659
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MRS. KELLY M SMITH
Credential	:	LPC LLP
Telephone Number	:	248-854-8659

Provider Enumeration Date	:	02/12/2022
Last Update Date	:	06/10/2022

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Directions to “KMS MENTAL HEALTH AND WELLNESS ” Practice Location

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