Basic Information
| Provider Information | |||||||||
| NPI: | 1336408533 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARNETT | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | LAVELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1589 | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720181589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013153344 | ||||||||
| FaxNumber: | 8705345798 | ||||||||
| Practice Location | |||||||||
| Address1: | 1628 E PAGE AVE | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013153344 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2012 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 8667-M | AR | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 8667-C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 116378726 | 05 | AR | MEDICAID |