Provider Demographics
NPI:1194894485
Name:WILBANKS, KEVIN SEAN (MA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:SEAN
Last Name:WILBANKS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 U ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-2154
Mailing Address - Country:US
Mailing Address - Phone:470-889-9360
Mailing Address - Fax:
Practice Address - Street 1:98 U ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-2154
Practice Address - Country:US
Practice Address - Phone:470-889-9360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003349101YP2500X
UT1396-4079-6004101YP2500X
ID7888101YP2500X
ORC8383101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA219822157OtherUNITED BEH. HEALTH
GA23652616OtherAETNA
GAC410947618OtherCELTIC INSURANCE
GA236474735AMedicaid
GA506632OtherVALUE OPTIONS
GA10041237Medicaid
GA280332000Medicaid
GA280332000OtherMAGELLAN B.H.