Healthcare Provider Details

I. General information

NPI: 1720368822
Provider Name (Legal Business Name): KEYSTONE COMMUNITY PARTNERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2321 CRABTREE BLVD SUITE 250
RALEIGH NC
27604-1567
US

IV. Provider business mailing address

3656 ROGERS RD SUITE 177
WAKE FOREST NC
27587-9306
US

V. Phone/Fax

Practice location:
  • Phone: 919-522-2508
  • Fax:
Mailing address:
  • Phone: 919-832-1011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. TANYA SMITH
Title or Position: ORGANIZATION ORGANIZER
Credential: M.A, LCAS-A
Phone: 919-522-2508