Healthcare Provider Details

I. General information

NPI: 1992129266
Provider Name (Legal Business Name): KEISHA MCLEAN-GREEN CCS, LCAS, MAC, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2014
Last Update Date: 07/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1977 J N PEASE PL STE 104
CHARLOTTE NC
28262-4528
US

IV. Provider business mailing address

1977 J N PEASE PL STE 104
CHARLOTTE NC
28262-4528
US

V. Phone/Fax

Practice location:
  • Phone: 704-215-4095
  • Fax: 704-271-1559
Mailing address:
  • Phone: 917-975-2675
  • Fax: 704-271-1559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number12321
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12321
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12321
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number00102070
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1828
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: