Healthcare Provider Details

I. General information

NPI: 1679390041
Provider Name (Legal Business Name): KENDRA AVILA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 CASCADE RD SE
GRAND RAPIDS MI
49546-3808
US

IV. Provider business mailing address

5060 CASCADE RD SE
GRAND RAPIDS MI
49546-3808
US

V. Phone/Fax

Practice location:
  • Phone: 423-314-9584
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: