1790522100 NPI number — KEESHANA C DICKENS LCSW-A, LCAS-A

NPI Number: 1790522100
Health Care Provider/Practitioner: KEESHANA C DICKENS LCSW-A, LCAS-A

NPI Number : 1790522100 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1790522100",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "DICKENS",
    "FirstName": "KEESHANA",
    "MiddleName": "C",
    "NamePrefix": "MS.",
    "NameSuffix": null,
    "Credential": "LCSW-A, LCAS-A",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "1317 LEGACY FALLS DR APT 101",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "WAKE FOREST",
    "MailingAddressStateName": "NC",
    "MailingAddressPostalCode": "27587-1873",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "252-289-5714",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "3117 POPLARWOOD CT STE 115",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "RALEIGH",
    "PracticeLocationAddressStateName": "NC",
    "PracticeLocationAddressPostalCode": "27604-1040",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "919-787-6131",
    "PracticeLocationAddressFaxNumber": "919-571-2932",
    "EnumerationDate": "07/11/2024",
    "LastUpdateDate": "12/16/2024",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "101YA0400X",
          "TaxonomyName": "Addiction (Substance Use Disorder) Counselor",
          "LicenseNumber": "LCAS-30073",
          "LicenseNumberStateCode": "NC",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "1041C0700X",
          "TaxonomyName": "Clinical Social Worker",
          "LicenseNumber": "P021081",
          "LicenseNumberStateCode": "NC",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}