Provider Demographics
NPI:1962750521
Name:WEIKUM, KEVIN LEE (MBA, MS SA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:WEIKUM
Suffix:
Gender:M
Credentials:MBA, MS SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3166 CHEROKEE STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144
Mailing Address - Country:US
Mailing Address - Phone:770-312-2598
Mailing Address - Fax:678-445-1456
Practice Address - Street 1:3166 CHEROKEE STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144
Practice Address - Country:US
Practice Address - Phone:770-312-2598
Practice Address - Fax:678-445-1456
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA08127444101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)