Provider Demographics
NPI:1013719152
Name:DOUGLASS, KENYETTA S
Entity type:Individual
Prefix:
First Name:KENYETTA
Middle Name:S
Last Name:DOUGLASS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 WERTZ AVE. NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-4171
Mailing Address - Country:US
Mailing Address - Phone:234-214-8470
Mailing Address - Fax:234-214-8471
Practice Address - Street 1:131 WERTZ AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-4171
Practice Address - Country:US
Practice Address - Phone:234-214-8470
Practice Address - Fax:234-214-8471
Is Sole Proprietor?:No
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005628175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist