Provider Demographics
NPI:1427409051
Name:BRANHAM, KAVIN (LCPC)
Entity type:Individual
Prefix:
First Name:KAVIN
Middle Name:
Last Name:BRANHAM
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-0018
Mailing Address - Country:US
Mailing Address - Phone:208-356-4900
Mailing Address - Fax:208-624-4030
Practice Address - Street 1:72 S 1ST E STE 103
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1965
Practice Address - Country:US
Practice Address - Phone:208-356-4900
Practice Address - Fax:208-624-4030
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-7894101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional