Provider Demographics
NPI:1003433558
Name:WHITE, KEISHA L (EDS, NCC,LAPC)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:L
Last Name:WHITE
Suffix:
Gender:F
Credentials:EDS, NCC,LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6873 SLATE STONE WAY SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5433
Mailing Address - Country:US
Mailing Address - Phone:404-914-8005
Mailing Address - Fax:
Practice Address - Street 1:500 LANIER AVE W STE 103B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7640
Practice Address - Country:US
Practice Address - Phone:404-800-4002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007240101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional