Provider Demographics
NPI:1194271452
Name:WILLIAMS, KENNETH DARNELL LORENZO
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DARNELL LORENZO
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20311 WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-1476
Mailing Address - Country:US
Mailing Address - Phone:248-416-8234
Mailing Address - Fax:
Practice Address - Street 1:20311 WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-1476
Practice Address - Country:US
Practice Address - Phone:248-416-8234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI452465135450173C00000X
MI7501006081225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist