Provider Demographics
NPI:1841806338
Name:RIVERS, KAIESHA LASZETTA (LMT, CLE, CLC)
Entity Type:Individual
Prefix:
First Name:KAIESHA
Middle Name:LASZETTA
Last Name:RIVERS
Suffix:
Gender:F
Credentials:LMT, CLE, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12750 FILBERT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-3937
Mailing Address - Country:US
Mailing Address - Phone:313-929-1979
Mailing Address - Fax:
Practice Address - Street 1:12750 FILBERT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-3937
Practice Address - Country:US
Practice Address - Phone:313-929-1979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-20
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501006796225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist