Provider Demographics
NPI:1982025458
Name:KENCAID, MYTIA
Entity Type:Individual
Prefix:
First Name:MYTIA
Middle Name:
Last Name:KENCAID
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 1:16200 CARRIAGE LAMP CT APT 702
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3520
Mailing Address - Country:US
Mailing Address - Phone:313-523-7477
Mailing Address - Fax:
Practice Address - Street 1:16200 CARRIAGE LAMP CT APT 702
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3520
Practice Address - Country:US
Practice Address - Phone:313-523-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-30
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7020815171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator