Provider Demographics
NPI:1275030181
Name:GLEAVE, KEVIN (CMT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GLEAVE
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 ATWELL ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-6471
Mailing Address - Country:US
Mailing Address - Phone:916-837-6582
Mailing Address - Fax:
Practice Address - Street 1:312 NATOMA ST STE 110
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-2692
Practice Address - Country:US
Practice Address - Phone:916-837-6582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-07
Last Update Date:2018-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67156225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist