Provider Demographics
NPI:1912414517
Name:REEDER, KIMBERLY (LCDCIII162243)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:REEDER
Suffix:
Gender:F
Credentials:LCDCIII162243
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 STANLEY ST
Mailing Address - Street 2:
Mailing Address - City:COAL GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45638-3148
Mailing Address - Country:US
Mailing Address - Phone:740-237-4981
Mailing Address - Fax:877-325-2816
Practice Address - Street 1:323 MARION PIKE STE 1
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638-2958
Practice Address - Country:US
Practice Address - Phone:740-237-4981
Practice Address - Fax:877-325-2816
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHW.1800091104100000X, 104100000X
171M00000X
OHLCDCIII.162243101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0257132Medicaid