Provider Demographics
NPI:1053433037
Name:LEWIS, KENYATTA FATINA (LLMSW)
Entity type:Individual
Prefix:MS
First Name:KENYATTA
Middle Name:FATINA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:MS
Other - First Name:KENYATTA
Other - Middle Name:FATINA
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LLMSW
Mailing Address - Street 1:41355 WILLIAMSBURG BLVD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3967
Mailing Address - Country:US
Mailing Address - Phone:734-895-1766
Mailing Address - Fax:
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:ADULT OUTPATIENT MENTAL HEALTH, SUITE 100
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-756-7705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010886371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical