Provider Demographics
NPI:1477670701
Name:LEAN, RONALD KEITH (PHD, LCS W)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:KEITH
Last Name:LEAN
Suffix:
Gender:M
Credentials:PHD, LCS W
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 SILAS CREEK PKWY STE 1A
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5000
Mailing Address - Country:US
Mailing Address - Phone:336-722-7300
Mailing Address - Fax:336-722-7311
Practice Address - Street 1:2200 SILAS CREEK PKWY STE 1A
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5000
Practice Address - Country:US
Practice Address - Phone:336-722-7300
Practice Address - Fax:336-722-7311
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0003321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC51340OtherBCBSNC
NC890294KMedicaid
NC890294KMedicaid
NC1581Medicare ID - Type UnspecifiedGROUP NUMBER