Provider Demographics
NPI:1205440195
Name:HARVELL, KEVIN EUGENE
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:EUGENE
Last Name:HARVELL
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 1:3435 GREENMOUNT AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-2942
Mailing Address - Country:US
Mailing Address - Phone:443-708-0360
Mailing Address - Fax:667-303-3152
Practice Address - Street 1:3435 GREENMOUNT AVE STE 1
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2942
Practice Address - Country:US
Practice Address - Phone:443-708-0360
Practice Address - Fax:667-303-3152
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000000000Medicaid