Healthcare Provider Details

I. General information

NPI: 1841806338
Provider Name (Legal Business Name): KAIESHA LASZETTA RIVERS LMT, CLE, CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2020
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29556 SOUTHFIELD RD STE 200
SOUTHFIELD MI
48076-2021
US

IV. Provider business mailing address

PO BOX 442030
DETROIT MI
48244-2030
US

V. Phone/Fax

Practice location:
  • Phone: 800-554-2503
  • Fax:
Mailing address:
  • Phone: 313-929-1979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501006796
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451025085
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: