Provider Demographics
NPI:1982830360
Name:THOMAS, KEVIN WAYNE
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:WAYNE
Last Name:THOMAS
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 1:51 WHEATLAND AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-2036
Mailing Address - Country:US
Mailing Address - Phone:617-824-0616
Mailing Address - Fax:617-533-7357
Practice Address - Street 1:1960 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-3219
Practice Address - Country:US
Practice Address - Phone:617-516-0289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-30
Last Update Date:2009-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health