Healthcare Provider Details

I. General information

NPI: 1437553419
Provider Name (Legal Business Name): GARY LAVELLE KEMPSON MSW., LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

673MDG 5955 ZEAMER AVENUE
JBER AK
99506
US

IV. Provider business mailing address

673MDG 5955 ZEAMER AVENUE
JBER AK
99506
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-3205
  • Fax:
Mailing address:
  • Phone: 907-580-3205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.700501
License Number StateAK
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.700501
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2871101
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: