Provider Demographics
NPI:1114631611
Name:FAUNTLEROY, KEVIN DURAN JR (MSW, ASW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DURAN
Last Name:FAUNTLEROY
Suffix:JR
Gender:M
Credentials:MSW, ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 ALLEN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553
Mailing Address - Country:US
Mailing Address - Phone:925-276-5853
Mailing Address - Fax:
Practice Address - Street 1:25 ALLEN ST
Practice Address - Street 2:SUITE B
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553
Practice Address - Country:US
Practice Address - Phone:925-276-5853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health