Provider Demographics
NPI:1346858347
Name:DAVIS, KEVIN ALONZO (MS, LADC1, CCFC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ALONZO
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MS, LADC1, CCFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MEADOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7122
Mailing Address - Country:US
Mailing Address - Phone:508-742-4400
Mailing Address - Fax:508-408-6175
Practice Address - Street 1:10 MEADOWBROOK RD
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7122
Practice Address - Country:US
Practice Address - Phone:508-742-4400
Practice Address - Fax:508-408-6175
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2415101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)