Provider Demographics
NPI:1598646218
Name:WHITEHEAD, KEVIN MOSES (EDS)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MOSES
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-2926
Mailing Address - Country:US
Mailing Address - Phone:317-226-4000
Mailing Address - Fax:
Practice Address - Street 1:522 WALLACE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-2926
Practice Address - Country:US
Practice Address - Phone:317-226-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-09
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10188121103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool