Provider Demographics
NPI:1275242869
Name:FACKLER, KEVIN GRANT (TSW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:GRANT
Last Name:FACKLER
Suffix:
Gender:M
Credentials:TSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4922 LAGOONA DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-5404
Mailing Address - Country:US
Mailing Address - Phone:502-396-2358
Mailing Address - Fax:
Practice Address - Street 1:4922 LAGOONA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-5404
Practice Address - Country:US
Practice Address - Phone:502-396-2358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99114992A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker