Provider Demographics
NPI:1669254751
Name:FLETCHER, KENYATA M (PHD, LPC, CRADC)
Entity type:Individual
Prefix:MS
First Name:KENYATA
Middle Name:M
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:PHD, LPC, CRADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1549 BALMORAL AVE
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-3638
Mailing Address - Country:US
Mailing Address - Phone:708-299-9282
Mailing Address - Fax:
Practice Address - Street 1:1549 BALMORAL AVE
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-3638
Practice Address - Country:US
Practice Address - Phone:708-299-9282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL25645101YA0400X
IL178.019144101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)