Basic Information
| Provider Information | |||||||||
| NPI: | 1104238054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANFIELD | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | CONUSELOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 ELSINORE PL | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452021459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8335104357 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4135 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | ELSMERE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410181815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8335104357 | ||||||||
| FaxNumber: | 8664602997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2014 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 175309 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1104238054 | 05 | KY | MEDICAID |