Provider Demographics
NPI:1154700490
Name:KENYATTA, LAWRENCE SR (BA CADC)
Entity type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:
Last Name:KENYATTA
Suffix:SR
Gender:M
Credentials:BA CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 W GRAND BLVD
Mailing Address - Street 2:SUITE 370
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3046
Mailing Address - Country:US
Mailing Address - Phone:313-456-6006
Mailing Address - Fax:313-935-9311
Practice Address - Street 1:3031 W GRAND BLVD
Practice Address - Street 2:SUITE 370
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3046
Practice Address - Country:US
Practice Address - Phone:313-456-6006
Practice Address - Fax:313-935-9311
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)