Healthcare Provider Details

I. General information

NPI: 1053516328
Provider Name (Legal Business Name): KENYATTA ETCHISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 E NEWTON ST
BOSTON MA
02118-2340
US

IV. Provider business mailing address

290 QUARRY ST APT 415
QUINCY MA
02169-4151
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-4646
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: