Healthcare Provider Details

I. General information

NPI: 1790607778
Provider Name (Legal Business Name): KENYATTA TYEASE HATTEN IMH, MS, CBHCM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 ENTERPRISE RD STE 105
DEBARY FL
32713-2753
US

IV. Provider business mailing address

447 S SHELFER ST
QUINCY FL
32351-3680
US

V. Phone/Fax

Practice location:
  • Phone: 850-728-0300
  • Fax:
Mailing address:
  • Phone: 850-728-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH285384
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: