Provider Demographics
NPI:1982947164
Name:MOORE, KEVIN
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:MOORE
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 1:107 HILL ST
Mailing Address - Street 2:APT. 9
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3720
Mailing Address - Country:US
Mailing Address - Phone:617-935-1510
Mailing Address - Fax:
Practice Address - Street 1:107 HILL ST
Practice Address - Street 2:APT. 9
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3720
Practice Address - Country:US
Practice Address - Phone:617-935-1510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health