Provider Demographics
NPI:1386450286
Name:HALL, KEVIN MATTHEW
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MATTHEW
Last Name:HALL
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 1:1500 S DOUGLAS RD STE 230
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4108
Mailing Address - Country:US
Mailing Address - Phone:844-244-1818
Mailing Address - Fax:
Practice Address - Street 1:42850 GARFIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-5026
Practice Address - Country:US
Practice Address - Phone:586-261-8524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-05
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MIH400465589432106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician