Healthcare Provider Details

I. General information

NPI: 1376860643
Provider Name (Legal Business Name): TYLER BROOKS KEZIAH LPC, LCAS, CSI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W WALKER AVE
ASHEBORO NC
27203-6760
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR SUITE 100
CONCORD NC
28025-1831
US

V. Phone/Fax

Practice location:
  • Phone: 336-633-7000
  • Fax: 336-625-3817
Mailing address:
  • Phone: 704-939-1100
  • Fax: 704-939-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1889
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number7792
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: