Provider Demographics
NPI:1689195919
Name:BROWN, KANEISHA (LLPC, NCC)
Entity Type:Individual
Prefix:
First Name:KANEISHA
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:LLPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22170 GARDNER ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2684
Mailing Address - Country:US
Mailing Address - Phone:248-752-1512
Mailing Address - Fax:
Practice Address - Street 1:1685 BALDWIN AVE STE 100
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-1115
Practice Address - Country:US
Practice Address - Phone:248-706-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015464101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional