Provider Demographics
NPI:1639845357
Name:ETTEMA, KENDRA (CTRS, MDIV)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:ETTEMA
Suffix:
Gender:F
Credentials:CTRS, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2664 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3728
Mailing Address - Country:US
Mailing Address - Phone:810-358-4064
Mailing Address - Fax:
Practice Address - Street 1:38257 MOUND RD BLDG D
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-3466
Practice Address - Country:US
Practice Address - Phone:586-722-7524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-22
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI59050225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Single Specialty