Provider Demographics
NPI:1356920532
Name:PANGBURN, KEVIN J (LCADC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:PANGBURN
Suffix:
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 BUCK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:FLOYDS KNOBS
Mailing Address - State:IN
Mailing Address - Zip Code:47119-9216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4200 BUCK CREEK RD
Practice Address - Street 2:
Practice Address - City:FLOYDS KNOBS
Practice Address - State:IN
Practice Address - Zip Code:47119-9216
Practice Address - Country:US
Practice Address - Phone:502-861-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100730680Medicaid