Provider Demographics
NPI:1316615305
Name:BLOUNT, KENDRA (MS)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 AXTELL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4400
Mailing Address - Country:US
Mailing Address - Phone:248-862-1171
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL DR STE 100
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4400
Practice Address - Country:US
Practice Address - Phone:248-862-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2023-03-07
Deactivation Date:2021-10-02
Deactivation Code:
Reactivation Date:2022-09-29
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other