Basic Information
Provider Information | |||||||||
NPI: | 1700297298 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BALDWIN | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | I | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BALDWIN | ||||||||
OtherFirstName: | KEVIN | ||||||||
OtherMiddleName: | JONATHAN | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: | I | ||||||||
OtherCredential: | CADC-M | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 12501 HAMILTON AVE | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND PARK | ||||||||
State: | MI | ||||||||
PostalCode: | 482033243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3138651580 | ||||||||
FaxNumber: | 3138651582 | ||||||||
Practice Location | |||||||||
Address1: | 12501 HAMILTON | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND PARK | ||||||||
State: | MI | ||||||||
PostalCode: | 48203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3138651580 | ||||||||
FaxNumber: | 3138651582 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2014 | ||||||||
LastUpdateDate: | 05/19/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   | MI | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.