Provider Demographics
NPI:1073799227
Name:BRYAN, KEISHA HINTON (LCSW, LCAS)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:HINTON
Last Name:BRYAN
Suffix:
Gender:F
Credentials:LCSW, LCAS
Other - Prefix:
Other - First Name:KEISHA
Other - Middle Name:MICHELLE
Other - Last Name:HINTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, LCAS
Mailing Address - Street 1:4905 RAVELSTONE CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-2897
Mailing Address - Country:US
Mailing Address - Phone:919-520-9392
Mailing Address - Fax:919-261-1675
Practice Address - Street 1:1008 BIG OAK CT STE F
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-6566
Practice Address - Country:US
Practice Address - Phone:919-520-9392
Practice Address - Fax:919-261-1675
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6112015Medicaid
NC6112015Medicaid
NCQ407290281Medicare PIN