Provider Demographics
NPI:1356489397
Name:HAYMON, KE-VYN TS (LADC)
Entity Type:Individual
Prefix:MR
First Name:KE-VYN
Middle Name:TS
Last Name:HAYMON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 MADISON ST
Mailing Address - Street 2:2
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-2231
Mailing Address - Country:US
Mailing Address - Phone:617-623-1814
Mailing Address - Fax:617-623-1817
Practice Address - Street 1:26 MADISON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155
Practice Address - Country:US
Practice Address - Phone:617-623-1814
Practice Address - Fax:617-623-1817
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA879101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)