1124124151 NPI number — LISA J. KEITH, LCSW, PLLC

Table of content: (NPI 1386340297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124124151 NPI number — LISA J. KEITH, LCSW, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LISA J. KEITH, LCSW, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124124151
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 ADLER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOLDSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27530-5513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-580-0790
Provider Business Mailing Address Fax Number:
919-735-9238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 ADLER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOLDSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27530-5513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-580-0790
Provider Business Practice Location Address Fax Number:
919-735-9238
Provider Enumeration Date:
09/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KEITH
Authorized Official First Name:
LISA
Authorized Official Middle Name:
JOHNSON
Authorized Official Title or Position:
MANAGER/PARTNER
Authorized Official Telephone Number:
919-922-2055

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C002693 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6005936 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 785920000 . This is a "MAGELLAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 142JF . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 190281 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".