1740622836 NPI number — KEVIN GARNER SAMPLE LCSW, LADC

Table of content: KEVIN GARNER SAMPLE LCSW, LADC (NPI 1740622836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740622836 NPI number — KEVIN GARNER SAMPLE LCSW, LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMPLE
Provider First Name:
KEVIN
Provider Middle Name:
GARNER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW, LADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740622836
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 630
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALAIS
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04619-0630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-751-8712
Provider Business Mailing Address Fax Number:
207-454-0775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
EASTPORT HEALTH CARE
Provider Second Line Business Practice Location Address:
30 BOYNTON STREET
Provider Business Practice Location Address City Name:
EASTPORT
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-853-0185
Provider Business Practice Location Address Fax Number:
207-853-4248
Provider Enumeration Date:
07/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LC15430 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010276859 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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