Provider Demographics
NPI:1538669635
Name:WEATHERSBY, KENYATTA D
Entity Type:Individual
Prefix:
First Name:KENYATTA
Middle Name:D
Last Name:WEATHERSBY
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 1:3925 N. MARTIN LUTHER KING BLVD
Mailing Address - Street 2:STE 211
Mailing Address - City:N. LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89301
Mailing Address - Country:US
Mailing Address - Phone:909-269-4906
Mailing Address - Fax:
Practice Address - Street 1:3925 N. MARTIN LUTHER KING BLVD
Practice Address - Street 2:STE 211
Practice Address - City:N. LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89301
Practice Address - Country:US
Practice Address - Phone:909-269-4906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health