Provider Demographics
NPI:1982123006
Name:HEUVELMAN, KENNETH SHINE (MS, CAADC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:SHINE
Last Name:HEUVELMAN
Suffix:
Gender:M
Credentials:MS, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3522 HOLLAND PARK LN
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-1558
Mailing Address - Country:US
Mailing Address - Phone:810-241-3605
Mailing Address - Fax:
Practice Address - Street 1:3522 HOLLAND PARK LN
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-241-3605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-03596101YA0400X
MTBBH-LAC-LIC-24075101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)