Provider Demographics
NPI:1225913445
Name:MONTEMAYOR, KENNETH T (MS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:T
Last Name:MONTEMAYOR
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-3038
Mailing Address - Country:US
Mailing Address - Phone:313-578-0570
Mailing Address - Fax:
Practice Address - Street 1:3135 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5131
Practice Address - Country:US
Practice Address - Phone:248-206-0486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-07
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352001070103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical