NPIMap

Individual provider Active NPI

Kathy M Khommanyvong, LMSW

  • Clinical Social Worker
  • Fort Dodge, IA
National Provider Identifier
1033250402
Registry record updated Feb 9, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Social WorkerTaxonomy code 1041C0700X
License
03941 Issued in IA
Practice address
720 Kenyon Rd
North Central Iowa MHC Dba Berryhill Center for Mental
Fort Dodge, IA 50501-0000
Phone
(515) 955-7171
Fax
(515) 573-7898
NPI assigned
Feb 9, 2007
Last updated
Feb 9, 2009By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 9, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Social Worker 1041C0700X 03941 IA Primary

Addresses

Primary practice location

720 Kenyon Rd
North Central Iowa MHC Dba Berryhill Center for Mental
Fort Dodge, IA 50501-0000

Mailing address

720 Kenyon Rd
North Central Iowa MHC Dba Berryhill Center for Mental
Fort Dodge, IA 50501-0000
Phone (515) 955-7171

Other identifiers 2

IdentifierTypeStateIssuer
0159608MedicaidIA
07466OtherIAWELLMARK BC/BS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled

State licenses

LicenseStateTypeSpecialty
03941IAMDClinical Social Worker

Practice roles

OrganizationSpecialtyStatusNew patients
North Central Iowa Mental Health Center Inc Past Accepting new patients
North Central Iowa Mental Health Center Inc Past Accepting new patients
North Central Iowa Mental Health Center, Inc Past Accepting new patients
North Central Iowa Mental Health Center, Inc Past Accepting new patients
North Central Iowa Mental Health Center, Inc Past Accepting new patients
North Central Iowa Mental Health Center Inc Past Accepting new patients

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170979200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1234137600000",
    "number": "1033250402",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "720 KENYON RD",
            "address_2": "NORTH CENTRAL IOWA MHC DBA BERRYHILL CENTER FOR MENTAL",
            "city": "FORT DODGE",
            "state": "IA",
            "postal_code": "505010000",
            "telephone_number": "515-955-7171",
            "fax_number": "515-573-7898"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "720 KENYON RD",
            "address_2": "NORTH CENTRAL IOWA MHC DBA BERRYHILL CENTER FOR MENTAL",
            "city": "FORT DODGE",
            "state": "IA",
            "postal_code": "505010000",
            "telephone_number": "515-955-7171",
            "fax_number": "515-573-7898"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KHOMMANYVONG",
        "first_name": "KATHY",
        "middle_name": "M",
        "credential": "LMSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-02-09",
        "last_updated": "2009-02-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "IA",
            "license": "03941",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0159608",
            "state": "IA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WELLMARK BC/BS",
            "identifier": "07466",
            "state": "IA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Dodge, IA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 9, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.