Provider Demographics
NPI:1043991540
Name:TRENT-JOHNSON, KENNETH RAY
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RAY
Last Name:TRENT-JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52632 SEVEN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-2985
Mailing Address - Country:US
Mailing Address - Phone:586-819-9825
Mailing Address - Fax:
Practice Address - Street 1:16700 17 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-7325
Practice Address - Country:US
Practice Address - Phone:586-228-2300
Practice Address - Fax:586-228-2300
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician