Provider Demographics
NPI:1003459314
Name:JOHN, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:JOHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48143-0663
Mailing Address - Country:US
Mailing Address - Phone:810-559-2129
Mailing Address - Fax:
Practice Address - Street 1:69068 BEEBE ST APT 86
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MI
Practice Address - Zip Code:48062-1511
Practice Address - Country:US
Practice Address - Phone:810-599-2129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician