Provider Demographics
NPI:1942733654
Name:WHITFIELD, KEVIN R (MA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:WHITFIELD
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 1:214 RUSKIN DR E
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-8411
Mailing Address - Country:US
Mailing Address - Phone:562-519-8808
Mailing Address - Fax:
Practice Address - Street 1:214 RUSKIN DR E
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356-8411
Practice Address - Country:US
Practice Address - Phone:562-519-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140004493103TS0200X
TX872656103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool