Provider Demographics
NPI:1053552489
Name:FENNELL, KEVA JAY
Entity type:Individual
Prefix:MRS
First Name:KEVA
Middle Name:JAY
Last Name:FENNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 FAIRFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-6842
Mailing Address - Country:US
Mailing Address - Phone:910-273-8060
Mailing Address - Fax:
Practice Address - Street 1:941 S MCPHERSON CHURCH RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5369
Practice Address - Country:US
Practice Address - Phone:910-483-5744
Practice Address - Fax:910-483-5494
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-14
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7361101YP2500X
NC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104171Medicaid