Provider Demographics
NPI:1326386053
Name:WILLIAMS, KENYATTA RASHON (MA, LCAS-A)
Entity Type:Individual
Prefix:MR
First Name:KENYATTA
Middle Name:RASHON
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MA, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2028 PHEASANT GLEN RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-8208
Mailing Address - Country:US
Mailing Address - Phone:704-705-0640
Mailing Address - Fax:
Practice Address - Street 1:2028 PHEASANT GLEN RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28214-8208
Practice Address - Country:US
Practice Address - Phone:704-705-0640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2828-A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)