Provider Demographics
NPI:1154955946
Name:KENT, KEVIN D
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:KENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 CHARLES PARTIN DR
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-1243
Mailing Address - Country:US
Mailing Address - Phone:857-500-3381
Mailing Address - Fax:
Practice Address - Street 1:4715 CHARLES PARTIN DR
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-1243
Practice Address - Country:US
Practice Address - Phone:857-500-3381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-23-69972103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid
FL111299000Medicaid