Provider Demographics
NPI:1962250274
Name:WIGGINS, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WIGGINS
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 1:323 COBBLESTONE CT
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-1823
Mailing Address - Country:US
Mailing Address - Phone:919-593-9392
Mailing Address - Fax:
Practice Address - Street 1:314 CHAPANOKE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-3400
Practice Address - Country:US
Practice Address - Phone:919-773-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20-125367106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician