Provider Demographics
NPI:1609639798
Name:SILVA, KEVAN JOSEPH
Entity Type:Individual
Prefix:
First Name:KEVAN
Middle Name:JOSEPH
Last Name:SILVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-3155
Mailing Address - Country:US
Mailing Address - Phone:774-398-3646
Mailing Address - Fax:
Practice Address - Street 1:95 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-3155
Practice Address - Country:US
Practice Address - Phone:774-398-3646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARBT-23-255787106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician