1639866494 NPI number — KEOTIA EVETTE SMITHERMAN CASTERLOW LCMHCA

Table of content: KEOTIA EVETTE SMITHERMAN CASTERLOW LCMHCA (NPI 1639866494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639866494 NPI number — KEOTIA EVETTE SMITHERMAN CASTERLOW LCMHCA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTERLOW
Provider First Name:
KEOTIA
Provider Middle Name:
EVETTE SMITHERMAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCMHCA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITHERMAN
Provider Other First Name:
KEOTIA
Provider Other Middle Name:
EVETTE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639866494
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1592 CANDACE RIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27406-8595
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-509-7616
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 EXECUTIVE PARK BLVD STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-1534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-509-7616
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/21/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  A18588 , 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)





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