Provider Demographics
NPI:1437828340
Name:PRINCE, KEASIA Z
Entity Type:Individual
Prefix:
First Name:KEASIA
Middle Name:Z
Last Name:PRINCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEASIA
Other - Middle Name:
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1990 PITTSTON FARM RD
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-5087
Mailing Address - Country:US
Mailing Address - Phone:404-432-7438
Mailing Address - Fax:
Practice Address - Street 1:2215 EXCHANGE PL SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6723
Practice Address - Country:US
Practice Address - Phone:770-679-0586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health