Provider Demographics
NPI:1144394073
Name:LOOMIS, KEVIN ROBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ROBERT
Last Name:LOOMIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1601 MILLTOWN RD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-4027
Mailing Address - Country:US
Mailing Address - Phone:302-995-9188
Mailing Address - Fax:302-995-9189
Practice Address - Street 1:1601 MILLTOWN RD
Practice Address - Street 2:SUITE 14
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-4027
Practice Address - Country:US
Practice Address - Phone:302-995-9188
Practice Address - Fax:302-995-9189
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB1-0000219103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEP10289Medicare UPIN