Provider Demographics
NPI:1780340901
Name:HALVORSEN, KEVIN ALEXANDER STICKNEY
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ALEXANDER STICKNEY
Last Name:HALVORSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 E 46TH CT APT 1
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-7519
Mailing Address - Country:US
Mailing Address - Phone:907-952-8158
Mailing Address - Fax:
Practice Address - Street 1:925 E 46TH CT APT 1
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-7519
Practice Address - Country:US
Practice Address - Phone:907-952-8158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK208193103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist