Provider Demographics
NPI:1386397537
Name:WHITE, KENYATA MONIQUE (LPTA)
Entity type:Individual
Prefix:
First Name:KENYATA
Middle Name:MONIQUE
Last Name:WHITE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5334 FREDELIA DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-1528
Mailing Address - Country:US
Mailing Address - Phone:810-874-5210
Mailing Address - Fax:
Practice Address - Street 1:4560 W ALEXIS RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-1082
Practice Address - Country:US
Practice Address - Phone:419-472-7115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA012576225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant