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General NPI Number Information
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NPI Number | 1790522100
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Entity Type | Individual
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Provider Name | KEESHANA C DICKENS LCSW-A, LCAS-A
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Gender | Female
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Dates
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Enumeration Date | 07/11/2024
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Last Update Date | 12/16/2024
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Provider Practice Location Address
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Address Line | 3117 POPLARWOOD CT STE 115
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City | RALEIGH
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State | NC
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Zip | 27604-1040
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Country | US
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Telephone | 919-787-6131
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Fax | 919-571-2932
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Provider Business Mailing Address
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Address Line | 1317 LEGACY FALLS DR APT 101
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City | WAKE FOREST
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State | NC
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Zip | 27587-1873
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Country | US
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Telephone | 252-289-5714
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LCAS-30073
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | P021081
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License Number State | NC
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