Basic Information
| Provider Information | |||||||||
| NPI: | 1235395419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIVENS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | KYLE | ||||||||
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| Credential: | LCSW-C , LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 MADISON ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200112311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027501246 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 604 SOLAREX CT | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217037005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016638263 | ||||||||
| FaxNumber: | 3016825326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2008 | ||||||||
| LastUpdateDate: | 08/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 13462 | MD | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LC50079737 | DC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 047788688 | 05 | DC | MEDICAID |