Provider Demographics
NPI:1851762926
Name:EVANS, KENYETTA
Entity Type:Individual
Prefix:MS
First Name:KENYETTA
Middle Name:
Last Name:EVANS
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 1:223 BELMONT RD
Mailing Address - Street 2:
Mailing Address - City:DIXONS MILLS
Mailing Address - State:AL
Mailing Address - Zip Code:36736-2855
Mailing Address - Country:US
Mailing Address - Phone:205-310-8033
Mailing Address - Fax:
Practice Address - Street 1:129 CLARK ST
Practice Address - Street 2:
Practice Address - City:GROVE HILL
Practice Address - State:AL
Practice Address - Zip Code:36451-3050
Practice Address - Country:US
Practice Address - Phone:251-275-4165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALADC842101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)