=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437649191
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEISHA SAMARA HORTON MS, NCC, LPCA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2018
-----------------------------------------------------
Last Update Date | 05/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 152 WIND CHIME CT
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27615-6433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 984-200-6058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4072 CLINARD AVE
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27127-6060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-608-8884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | A13688
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------