Provider Demographics
NPI:1568983914
Name:FARRIS, KEVIN D (LLBSW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:FARRIS
Suffix:
Gender:M
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 83
Mailing Address - Street 2:
Mailing Address - City:PIONEER
Mailing Address - State:OH
Mailing Address - Zip Code:43554-0083
Mailing Address - Country:US
Mailing Address - Phone:517-662-9759
Mailing Address - Fax:
Practice Address - Street 1:1040 S WINTER ST STE 1022
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-3876
Practice Address - Country:US
Practice Address - Phone:517-263-8905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI6802090452171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician