Provider Demographics
NPI:1427877299
Name:BLACK, KENDRA AISHA (LMSW)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:AISHA
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KIYA
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:1548 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2432
Mailing Address - Country:US
Mailing Address - Phone:901-538-8952
Mailing Address - Fax:901-333-8255
Practice Address - Street 1:1548 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2432
Practice Address - Country:US
Practice Address - Phone:901-538-8952
Practice Address - Fax:901-333-8255
Is Sole Proprietor?:No
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR-13092101YM0800X
MSMS-M10738101YM0800X
TNTN-12523101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health