Provider Demographics
NPI:1225760614
Name:STANSBURY, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:STANSBURY
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 1:306 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-1305
Mailing Address - Country:US
Mailing Address - Phone:316-616-4681
Mailing Address - Fax:
Practice Address - Street 1:5500 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1607
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-26
Last Update Date:2022-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS96691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical