Provider Demographics
NPI:1619031390
Name:KERVICK, KEVIN JOSEPH (MS)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOSEPH
Last Name:KERVICK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ELM ST # 931
Mailing Address - Street 2:
Mailing Address - City:BRIDGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04009-1263
Mailing Address - Country:US
Mailing Address - Phone:603-319-1035
Mailing Address - Fax:
Practice Address - Street 1:6 ELM ST # 931
Practice Address - Street 2:
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04009-1263
Practice Address - Country:US
Practice Address - Phone:603-319-1035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHEL0320106H00000X
IDLMFT-8157106H00000X
MEMF5421106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist