Provider Demographics
NPI:1760013767
Name:MCCORKLE, KENON LEVAR
Entity Type:Individual
Prefix:
First Name:KENON
Middle Name:LEVAR
Last Name:MCCORKLE
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 1:1504 JAKE ALEXANDER BLVD W
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-1213
Mailing Address - Country:US
Mailing Address - Phone:704-645-8540
Mailing Address - Fax:
Practice Address - Street 1:1504 JAKE ALEXANDER BLVD W
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1213
Practice Address - Country:US
Practice Address - Phone:704-645-8540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)