Provider Demographics
NPI:1851639488
Name:MOYER-WILKES, KEVIN JAMES (MED, NCC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAMES
Last Name:MOYER-WILKES
Suffix:
Gender:M
Credentials:MED, NCC
Other - Prefix:MR
Other - First Name:KEVIN
Other - Middle Name:JAMES
Other - Last Name:WILKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, NCC
Mailing Address - Street 1:16 SAXON RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-1522
Mailing Address - Country:US
Mailing Address - Phone:508-869-0197
Mailing Address - Fax:508-869-0313
Practice Address - Street 1:1 ELMWOOD PL
Practice Address - Street 2:
Practice Address - City:BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01505-2040
Practice Address - Country:US
Practice Address - Phone:508-869-0197
Practice Address - Fax:508-869-0313
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA463166101YS0200X
CTC062011002701101YS0200X
PA10606058101YS0200X
MA322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool