Healthcare Provider Details

I. General information

NPI: 1285589887
Provider Name (Legal Business Name): KIESHA LAQUANTIA COUSAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2026
Last Update Date: 02/28/2026
Certification Date: 02/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8480 HONEYCUTT RD STE 200
RALEIGH NC
27615-2261
US

IV. Provider business mailing address

4441 SIX FORKS RD STE 106
RALEIGH NC
27609-5729
US

V. Phone/Fax

Practice location:
  • Phone: 919-885-4042
  • Fax:
Mailing address:
  • Phone: 919-885-4042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA20929
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: