Healthcare Provider Details

I. General information

NPI: 1982947164
Provider Name (Legal Business Name): MR. KEVIN MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 04/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 HILL ST APT. 9
STONEHAM MA
02180-3720
US

IV. Provider business mailing address

107 HILL ST APT. 9
STONEHAM MA
02180-3720
US

V. Phone/Fax

Practice location:
  • Phone: 617-935-1510
  • Fax:
Mailing address:
  • Phone: 617-935-1510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: