Provider Demographics
NPI:1073746772
Name:PEMBERTON, KEITH G I (MSW, P-LCSW)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:G
Last Name:PEMBERTON
Suffix:I
Gender:M
Credentials:MSW, P-LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1589 SKEET CLUB RD
Mailing Address - Street 2:SUITE 102-251
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-8817
Mailing Address - Country:US
Mailing Address - Phone:336-420-5366
Mailing Address - Fax:
Practice Address - Street 1:801 SUMMIT AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-7856
Practice Address - Country:US
Practice Address - Phone:336-674-9781
Practice Address - Fax:866-631-6282
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP003878101YM0800X, 104100000X, 1041C0700X
NC1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool