Provider Demographics
NPI:1619679644
Name:FRALEY, KEVIN EUGENE JR (LMHC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:EUGENE
Last Name:FRALEY
Suffix:JR
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4453 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-2066
Mailing Address - Country:US
Mailing Address - Phone:850-905-0110
Mailing Address - Fax:
Practice Address - Street 1:4453 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-2066
Practice Address - Country:US
Practice Address - Phone:850-905-0110
Practice Address - Fax:850-905-8600
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21975101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health