Provider Demographics
NPI:1245794676
Name:CLEGG, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CLEGG
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 1:3993 MEETING ST
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569-3053
Mailing Address - Country:US
Mailing Address - Phone:843-756-3008
Mailing Address - Fax:
Practice Address - Street 1:3993 MEETING ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-3053
Practice Address - Country:US
Practice Address - Phone:843-756-3008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health