Provider Demographics
NPI:1740622836
Name:SAMPLE, KEVIN GARNER (LCSW, LADC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:GARNER
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:LCSW, LADC
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 630
Mailing Address - Street 2:
Mailing Address - City:CALAIS
Mailing Address - State:ME
Mailing Address - Zip Code:04619-0630
Mailing Address - Country:US
Mailing Address - Phone:207-751-8712
Mailing Address - Fax:207-454-0775
Practice Address - Street 1:EASTPORT HEALTH CARE
Practice Address - Street 2:30 BOYNTON STREET
Practice Address - City:EASTPORT
Practice Address - State:ME
Practice Address - Zip Code:04631
Practice Address - Country:US
Practice Address - Phone:207-853-0185
Practice Address - Fax:207-853-4248
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC154301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME010276859Medicaid