Provider Demographics
NPI:1366236788
Name:UNDERWOOD, KYSHA (LCADC)
Entity type:Individual
Prefix:
First Name:KYSHA
Middle Name:
Last Name:UNDERWOOD
Suffix:
Gender:X
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 COLTS NECK DR
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-5644
Mailing Address - Country:US
Mailing Address - Phone:856-383-9359
Mailing Address - Fax:
Practice Address - Street 1:24 COLTS NECK DR
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-5644
Practice Address - Country:US
Practice Address - Phone:856-383-9359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00288500101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)