Provider Demographics
NPI:1336408533
Name:BARNETT, KEVIN LAVELLE
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LAVELLE
Last Name:BARNETT
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:PO BOX 1589
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-1589
Mailing Address - Country:US
Mailing Address - Phone:501-315-3344
Mailing Address - Fax:870-534-5798
Practice Address - Street 1:1628 E PAGE AVE
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104
Practice Address - Country:US
Practice Address - Phone:501-315-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
AR8667-M104100000X
AR8667-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116378726Medicaid