Provider Demographics
NPI:1366860637
Name:WITHERSPOON, KENOSHA (BS)
Entity Type:Individual
Prefix:
First Name:KENOSHA
Middle Name:
Last Name:WITHERSPOON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9365 E OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-1507
Mailing Address - Country:US
Mailing Address - Phone:313-695-5416
Mailing Address - Fax:
Practice Address - Street 1:9365 E OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-1507
Practice Address - Country:US
Practice Address - Phone:313-695-5416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency