Provider Demographics
NPI:1154831568
Name:AHN, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:AHN
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:PSC 475 BOX 8
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96350-9998
Mailing Address - Country:US
Mailing Address - Phone:315-243-8649
Mailing Address - Fax:
Practice Address - Street 1:PSC 475 BOX 1
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96350-1200
Practice Address - Country:US
Practice Address - Phone:315-243-5171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD193531041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty