Provider Demographics
NPI:1679029136
Name:ROTIBI, KENISHA
Entity Type:Individual
Prefix:
First Name:KENISHA
Middle Name:
Last Name:ROTIBI
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 1:5963 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-0444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5963 RIDGEWAY DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-0444
Practice Address - Country:US
Practice Address - Phone:972-890-6101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX556031041C0700X
172V00000X, 251S00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No172V00000XOther Service ProvidersCommunity Health Worker
No251S00000XAgenciesCommunity/Behavioral Health