Provider Demographics
NPI:1114159928
Name:DELOACH, KEVIN L
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:L
Last Name:DELOACH
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 1:6111 CONAWAY DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6111 CONAWAY DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2700
Practice Address - Country:US
Practice Address - Phone:910-512-6760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health