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General NPI Number Information
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NPI Number | 1003459314
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Entity Type | Individual
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Provider Name | KEVIN JOHN
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Gender | Male
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Dates
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Enumeration Date | 10/21/2019
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Last Update Date | 10/21/2019
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Provider Practice Location Address
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Address Line | 69068 BEEBE ST APT 86
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City | RICHMOND
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State | MI
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Zip | 48062-1511
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Country | US
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Telephone | 810-599-2129
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 663
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City | LAKELAND
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State | MI
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Zip | 48143-0663
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Country | US
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Telephone | 810-559-2129
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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