Provider Demographics
NPI:1619031390
Name:KERVICK, KEVIN JOSEPH (MS)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOSEPH
Last Name:KERVICK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 W HONEYSUCKLE AVE UNIT 3414
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9910
Mailing Address - Country:US
Mailing Address - Phone:603-897-5504
Mailing Address - Fax:
Practice Address - Street 1:109 W HONEYSUCKLE AVE UNIT 3414
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9910
Practice Address - Country:US
Practice Address - Phone:603-897-5504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2025-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT-8157106H00000X
ID8187171400000X
MEMF5421106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171400000XOther Service ProvidersHealth & Wellness Coach