Provider Demographics
NPI:1093825473
Name:WILLOUGHBY, KEVIN (LCSW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 CUMBERLAND CIR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-9008
Mailing Address - Country:US
Mailing Address - Phone:270-901-5000
Mailing Address - Fax:270-842-5268
Practice Address - Street 1:380 SUWANNEE TRAIL STREET
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103
Practice Address - Country:US
Practice Address - Phone:270-901-5000
Practice Address - Fax:270-842-6553
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY12761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid
KY0257Medicare ID - Type UnspecifiedGROUP
KY25736Medicare PIN