Provider Demographics
NPI:1770163354
Name:REICH, KEVIN THOMAS (LGPC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:THOMAS
Last Name:REICH
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 WHIPS LN
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4855
Mailing Address - Country:US
Mailing Address - Phone:410-218-8083
Mailing Address - Fax:
Practice Address - Street 1:7811 WISE AVE
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-3339
Practice Address - Country:US
Practice Address - Phone:443-530-6533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP9173101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD832986042Medicaid