Provider Demographics
NPI:1790522100
Name:DICKENS, KEESHANA C (LCSW-A, LCAS-A)
Entity type:Individual
Prefix:MS
First Name:KEESHANA
Middle Name:C
Last Name:DICKENS
Suffix:
Gender:F
Credentials:LCSW-A, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 LEGACY FALLS DR APT 101
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-1873
Mailing Address - Country:US
Mailing Address - Phone:252-289-5714
Mailing Address - Fax:
Practice Address - Street 1:3117 POPLARWOOD CT STE 115
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1040
Practice Address - Country:US
Practice Address - Phone:919-787-6131
Practice Address - Fax:919-571-2932
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-30073101YA0400X
NCP0210811041C0700X, 1041C0700X
101YA0400X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty