Healthcare Provider Details

I. General information

NPI: 1245183052
Provider Name (Legal Business Name): KEVIN THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6072 BRYNWOOD DR STE 201
ROCKFORD IL
61114-5829
US

IV. Provider business mailing address

6072 BRYNWOOD DR STE 201
ROCKFORD IL
61114-5829
US

V. Phone/Fax

Practice location:
  • Phone: 779-363-4390
  • Fax:
Mailing address:
  • Phone: 779-363-4390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: