Healthcare Provider Details

I. General information

NPI: 1982123006
Provider Name (Legal Business Name): KENNETH SHINE HEUVELMAN LPC, CAADC, CCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 SUPERIOR ST
PORT HURON MI
48060-3838
US

IV. Provider business mailing address

3479 MINNIE DR
LAKEPORT MI
48059-1948
US

V. Phone/Fax

Practice location:
  • Phone: 810-984-4202
  • Fax:
Mailing address:
  • Phone: 810-637-1123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC-03596
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-LAC-LIC-24075
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451022467
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401225382
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: