Healthcare Provider Details

I. General information

NPI: 1619679644
Provider Name (Legal Business Name): KEVIN EUGENE FRALEY JR. LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4453 HIGHWAY 90
PACE FL
32571-2066
US

IV. Provider business mailing address

4453 HIGHWAY 90
PACE FL
32571-2066
US

V. Phone/Fax

Practice location:
  • Phone: 850-905-0110
  • Fax: 850-905-8600
Mailing address:
  • Phone: 850-905-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH21975
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: