Provider Demographics
NPI:1164785556
Name:WEATHERLY, KEVIN S (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:S
Last Name:WEATHERLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5604 WESLEY ST STE 104
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402-6326
Mailing Address - Country:US
Mailing Address - Phone:903-883-7792
Mailing Address - Fax:903-488-5303
Practice Address - Street 1:5604 WESLEY ST STE 104
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-6326
Practice Address - Country:US
Practice Address - Phone:903-883-7792
Practice Address - Fax:903-488-5303
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37657103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX375679301Medicaid