Provider Demographics
NPI:1497344808
Name:NIBLACK, KEESHA (LCSW)
Entity Type:Individual
Prefix:
First Name:KEESHA
Middle Name:
Last Name:NIBLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 BARNABY ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-1513
Mailing Address - Country:US
Mailing Address - Phone:732-685-4063
Mailing Address - Fax:
Practice Address - Street 1:1705 BARNABY ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-1513
Practice Address - Country:US
Practice Address - Phone:732-685-4063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00017711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical