Provider Demographics
NPI:1700297298
Name:BALDWIN, KEVIN I
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BALDWIN
Suffix:I
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:KEVIN
Other - Middle Name:JONATHAN
Other - Last Name:BALDWIN
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:CADC-M
Mailing Address - Street 1:12501 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3243
Mailing Address - Country:US
Mailing Address - Phone:313-865-1580
Mailing Address - Fax:313-865-1582
Practice Address - Street 1:12501 HAMILTON
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203
Practice Address - Country:US
Practice Address - Phone:313-865-1580
Practice Address - Fax:313-865-1582
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)