Provider Demographics
NPI:1396222410
Name:STATON, KENYETTA JEAN-MARIE
Entity Type:Individual
Prefix:
First Name:KENYETTA
Middle Name:JEAN-MARIE
Last Name:STATON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 N HOBART ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-4115
Mailing Address - Country:US
Mailing Address - Phone:267-461-7799
Mailing Address - Fax:
Practice Address - Street 1:551 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:HAVERFORD
Practice Address - State:PA
Practice Address - Zip Code:19041-1419
Practice Address - Country:US
Practice Address - Phone:610-525-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-21
Last Update Date:2018-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health