Healthcare Provider Details

I. General information

NPI: 1356489397
Provider Name (Legal Business Name): KE-VYN T.S. HAYMON LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 MADISON ST
MEDFORD MA
02155
US

IV. Provider business mailing address

26 MADISON ST 2
MEDFORD MA
02155-2231
US

V. Phone/Fax

Practice location:
  • Phone: 617-623-1814
  • Fax: 617-623-1817
Mailing address:
  • Phone: 617-623-1814
  • Fax: 617-623-1817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number879
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: