Healthcare Provider Details

I. General information

NPI: 1306294707
Provider Name (Legal Business Name): MS. KISSIE SHANTA WASHINGTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 09/29/2026
Certification Date: 12/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15476 ARCHDALE ST
DETROIT MI
48227-1506
US

IV. Provider business mailing address

15476 ARCHDALE ST
DETROIT MI
48227-1506
US

V. Phone/Fax

Practice location:
  • Phone: 248-249-3497
  • Fax:
Mailing address:
  • Phone: 248-249-3497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateOH
# 6
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number StateOH
# 8
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: