Healthcare Provider Details

I. General information

NPI: 1740622836
Provider Name (Legal Business Name): KEVIN GARNER SAMPLE LCSW, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EASTPORT HEALTH CARE 30 BOYNTON STREET
EASTPORT ME
04631
US

IV. Provider business mailing address

PO BOX 630
CALAIS ME
04619-0630
US

V. Phone/Fax

Practice location:
  • Phone: 207-853-0185
  • Fax: 207-853-4248
Mailing address:
  • Phone: 207-751-8712
  • Fax: 207-454-0775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC15430
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: