Provider Demographics
NPI:1316573538
Name:CHAVEZ, KEVIN A (SPTA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:SPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 S PACA ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-2527
Mailing Address - Country:US
Mailing Address - Phone:252-945-8532
Mailing Address - Fax:
Practice Address - Street 1:1111 SPRING ST STE 310
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-4003
Practice Address - Country:US
Practice Address - Phone:301-588-3929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDA5366225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program