Provider Demographics
NPI:1013628502
Name:MEEHAN, KEVIN JOHN (LICSW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOHN
Last Name:MEEHAN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-1330
Mailing Address - Country:US
Mailing Address - Phone:304-281-6942
Mailing Address - Fax:
Practice Address - Street 1:888 VANDALIA RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-6248
Practice Address - Country:US
Practice Address - Phone:304-281-6942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP004544551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty