Provider Demographics
NPI:1194718650
Name:CORREIA, KEVIN MARK (PHD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MARK
Last Name:CORREIA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8155 GLADYS AVE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-3243
Mailing Address - Country:US
Mailing Address - Phone:409-860-4007
Mailing Address - Fax:409-860-1762
Practice Address - Street 1:8155 GLADYS AVE
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706
Practice Address - Country:US
Practice Address - Phone:409-860-4007
Practice Address - Fax:409-860-1762
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31520103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0051GZOtherBLUE CROSS/BLUE SHIELD
TX7473360OtherAETNA
TX305188OtherCHAMPUS
TX1507170-01Medicaid
TX7473360OtherAETNA