Healthcare Provider Details

I. General information

NPI: 1164158531
Provider Name (Legal Business Name): KECIA WEST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1285 MARKS CHURCH RD STE F
AUGUSTA GA
30909-2472
US

IV. Provider business mailing address

2566 SHALLOWFORD RD NE STE 104-118
ATLANTA GA
30345-1249
US

V. Phone/Fax

Practice location:
  • Phone: 404-769-8771
  • Fax:
Mailing address:
  • Phone: 706-530-5397
  • Fax: 706-609-5753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: KECIA WEST
Title or Position: CEO
Credential: LPC
Phone: 706-530-5397