Healthcare Provider Details

I. General information

NPI: 1689930042
Provider Name (Legal Business Name): KEVIN DEYOUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 S WASHINGTON ST
OWOSSO MI
48867-2921
US

IV. Provider business mailing address

585 JEWETT RD
MASON MI
48854-8729
US

V. Phone/Fax

Practice location:
  • Phone: 989-723-0330
  • Fax: 989-723-0327
Mailing address:
  • Phone: 517-676-5405
  • Fax: 517-676-5460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801059279
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: