Provider Demographics
NPI:1043554454
Name:BROOKS, KYSHIA (LCAS/OWNER)
Entity Type:Individual
Prefix:
First Name:KYSHIA
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:LCAS/OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 HUGH HOWELL RD STE 430
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4722
Mailing Address - Country:US
Mailing Address - Phone:470-668-9295
Mailing Address - Fax:
Practice Address - Street 1:4500 HUGH HOWELL RD STE 430
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4722
Practice Address - Country:US
Practice Address - Phone:470-668-9295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2499-A101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008513Medicaid