Healthcare Provider Details

I. General information

NPI: 1194718650
Provider Name (Legal Business Name): KEVIN MARK CORREIA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8155 GLADYS AVE
BEAUMONT TX
77706
US

IV. Provider business mailing address

8155 GLADYS AVE
BEAUMONT TX
77706-3243
US

V. Phone/Fax

Practice location:
  • Phone: 409-860-4007
  • Fax: 409-860-1762
Mailing address:
  • Phone: 409-860-4007
  • Fax: 409-860-1762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number31520
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number31520
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: