Provider Demographics
NPI:1538568233
Name:REAL, RAKEYTA (SSP, LPES)
Entity type:Individual
Prefix:
First Name:RAKEYTA
Middle Name:
Last Name:REAL
Suffix:
Gender:F
Credentials:SSP, LPES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7625 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-1217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 E. LIBERTY STREET
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571
Practice Address - Country:US
Practice Address - Phone:843-423-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC268451103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool