Provider Demographics
NPI:1922269570
Name:BLOUNT, KEISHA J (MA,LCAS,CCS)
Entity type:Individual
Prefix:MS
First Name:KEISHA
Middle Name:J
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:MA,LCAS,CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 MOONSTONE CT
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-2682
Mailing Address - Country:US
Mailing Address - Phone:919-451-0072
Mailing Address - Fax:
Practice Address - Street 1:5312 SIX FORKS RD STE 301
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4458
Practice Address - Country:US
Practice Address - Phone:984-444-4741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1095251S00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251S00000XAgenciesCommunity/Behavioral Health