Provider Demographics
NPI:1144765017
Name:CONEY, KEISHA T (MA/ DIRECT STAFF)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:T
Last Name:CONEY
Suffix:
Gender:F
Credentials:MA/ DIRECT STAFF
Other - Prefix:
Other - First Name:KEISHA
Other - Middle Name:T
Other - Last Name:CONEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:TEACHER/STAFF
Mailing Address - Street 1:500 MILLER AVE
Mailing Address - Street 2:SPACE 67
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-3860
Mailing Address - Country:US
Mailing Address - Phone:702-972-7942
Mailing Address - Fax:
Practice Address - Street 1:500 MILLER AVE
Practice Address - Street 2:SPACE 67
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-3860
Practice Address - Country:US
Practice Address - Phone:702-972-7942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-30
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1704038143106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician