Healthcare Provider Details

I. General information

NPI: 1639845357
Provider Name (Legal Business Name): KENDRA ETTEMA CTRS, MDIV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2021
Last Update Date: 08/22/2021
Certification Date: 08/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38257 MOUND RD BLDG D
STERLING HEIGHTS MI
48310-3466
US

IV. Provider business mailing address

2664 WINDSOR DR
TROY MI
48085-3728
US

V. Phone/Fax

Practice location:
  • Phone: 586-722-7524
  • Fax:
Mailing address:
  • Phone: 810-358-4064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number59050
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: