Healthcare Provider Details

I. General information

NPI: 1073080834
Provider Name (Legal Business Name): KEVIN READ SMITH LEP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 W 23RD ST
MERCED CA
95340-3723
US

IV. Provider business mailing address

444 W 23RD ST
MERCED CA
95340-3723
US

V. Phone/Fax

Practice location:
  • Phone: 209-385-6649
  • Fax:
Mailing address:
  • Phone: 209-385-6649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLEP2724
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: