Provider Demographics
NPI:1558613513
Name:ELMORE, KEVIN JOHN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOHN
Last Name:ELMORE
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COUNTY SERVICES PKWY SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-4010
Mailing Address - Country:US
Mailing Address - Phone:678-681-4667
Mailing Address - Fax:
Practice Address - Street 1:1650 COUNTY SERVICES PKWY SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-4010
Practice Address - Country:US
Practice Address - Phone:678-681-4667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007419101YP2500X
GALPC009728101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional