Provider Demographics
NPI:1275691826
Name:FLETCHER, KINYATTA (BA)
Entity Type:Individual
Prefix:MS
First Name:KINYATTA
Middle Name:
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5540 TOWNSEND ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-2855
Mailing Address - Country:US
Mailing Address - Phone:586-758-6670
Mailing Address - Fax:
Practice Address - Street 1:23700 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1669
Practice Address - Country:US
Practice Address - Phone:586-758-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP12910Medicaid