Provider Demographics
NPI:1457611477
Name:KEVAN, MARA S (DACM, LAC, DIPLAC)
Entity Type:Individual
Prefix:DR
First Name:MARA
Middle Name:S
Last Name:KEVAN
Suffix:
Gender:F
Credentials:DACM, LAC, DIPLAC
Other - Prefix:DR
Other - First Name:MARA
Other - Middle Name:S
Other - Last Name:KEVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:740 4TH ST N # 195
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-2322
Mailing Address - Country:US
Mailing Address - Phone:727-677-8006
Mailing Address - Fax:
Practice Address - Street 1:111 2ND AVE NE STE 705
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3441
Practice Address - Country:US
Practice Address - Phone:727-677-8006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC158039171100000X
FL4079171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist