Provider Demographics
NPI:1316945504
Name:CORUM, KEVIN SCOTT (LCSW)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:SCOTT
Last Name:CORUM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2334 BOB CARNES RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37924-1801
Mailing Address - Country:US
Mailing Address - Phone:865-964-5882
Mailing Address - Fax:865-689-4443
Practice Address - Street 1:210 SIMMONS ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-4750
Practice Address - Country:US
Practice Address - Phone:865-970-9800
Practice Address - Fax:865-983-4518
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ031992Medicaid