Provider Demographics
NPI:1780934992
Name:EVERETT, KENYA (COTA)
Entity type:Individual
Prefix:
First Name:KENYA
Middle Name:
Last Name:EVERETT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3018
Mailing Address - Country:US
Mailing Address - Phone:414-277-8854
Mailing Address - Fax:414-276-2332
Practice Address - Street 1:1414 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3018
Practice Address - Country:US
Practice Address - Phone:414-277-8854
Practice Address - Fax:414-276-2332
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4847-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100032863Medicaid