Provider Demographics
NPI:1689751059
Name:DEVLIN, KENNETH J (MA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:J
Last Name:DEVLIN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 BLUE SULPHUR GDNS
Mailing Address - Street 2:
Mailing Address - City:ONA
Mailing Address - State:WV
Mailing Address - Zip Code:25545-9757
Mailing Address - Country:US
Mailing Address - Phone:304-634-7238
Mailing Address - Fax:304-733-2229
Practice Address - Street 1:3440 BLUE SULPHUR GDNS
Practice Address - Street 2:
Practice Address - City:ONA
Practice Address - State:WV
Practice Address - Zip Code:25545-9757
Practice Address - Country:US
Practice Address - Phone:304-634-7238
Practice Address - Fax:304-733-2229
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV362103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV021698OtherVALUE OPTIONS
WV1689751059OtherTRICARE
WV0163332000OtherAPS HEALTHCARE
WV0163332000Medicaid
WV1002524OtherBRICKSTREET
WV1689751059OtherMSBCBS
WV1689751059OtherSELECTNET
WV1689751059OtherSELECTNET
WVDE0658793Medicare ID - Type Unspecified
OH0944723OtherOHIO JOB AND FAMILY SERVICES
203735494OtherCOMPNET
WV20373549400OtherFEDERAL WORKER'S COMP
OH20373549400OtherOHIO BUREAU OF WORKER'S COMP
WV20-3735494OtherWELLS FARGO (PEIA)
TH9359501Medicare PIN