Healthcare Provider Details

I. General information

NPI: 1972368090
Provider Name (Legal Business Name): KEVIN MIKE KITTRELL JR. LGPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2024
Last Update Date: 02/19/2024
Certification Date: 02/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N HOWARD ST # 300
BALTIMORE MD
21218-5909
US

IV. Provider business mailing address

6726 DANVILLE AVE
DUNDALK MD
21222-1029
US

V. Phone/Fax

Practice location:
  • Phone: 443-438-6742
  • Fax:
Mailing address:
  • Phone: 443-320-3496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLGP14679
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: