Provider Demographics
NPI:1871984435
Name:STEPHENSON, KENYA (OWNER)
Entity type:Individual
Prefix:
First Name:KENYA
Middle Name:
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:KENYA
Other - Middle Name:TANDALAYA
Other - Last Name:STEPHENSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OWNER
Mailing Address - Street 1:314 CONLEY ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-1614
Mailing Address - Country:US
Mailing Address - Phone:252-916-1233
Mailing Address - Fax:
Practice Address - Street 1:314 CONLEY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-1614
Practice Address - Country:US
Practice Address - Phone:252-916-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X, 101YM0800X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1871984435Medicaid