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General NPI Number Information
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NPI Number | 1639845357
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Entity Type | Individual
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Provider Name | KENDRA ETTEMA CTRS, MDIV
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Gender | Female
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Dates
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Enumeration Date | 08/22/2021
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Last Update Date | 08/22/2021
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Provider Practice Location Address
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Address Line | 38257 MOUND RD BLDG D
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City | STERLING HEIGHTS
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State | MI
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Zip | 48310-3466
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Country | US
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Telephone | 586-722-7524
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Fax |
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Provider Business Mailing Address
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Address Line | 2664 WINDSOR DR
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City | TROY
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State | MI
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Zip | 48085-3728
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Country | US
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Telephone | 810-358-4064
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225800000X
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Taxonomy Name | Recreation Therapist
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License Number | 59050
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License Number State | MI
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