Provider Demographics
NPI:1518690064
Name:KENNEBREW, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:KENNEBREW
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 1:17653 FOX
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-2311
Mailing Address - Country:US
Mailing Address - Phone:334-320-6223
Mailing Address - Fax:
Practice Address - Street 1:17653 FOX
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-2311
Practice Address - Country:US
Practice Address - Phone:334-320-6223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician