Provider Demographics
NPI:1568472553
Name:PRUDEN, KEISCHA (LPC)
Entity Type:Individual
Prefix:MRS
First Name:KEISCHA
Middle Name:
Last Name:PRUDEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 885
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-0885
Mailing Address - Country:US
Mailing Address - Phone:252-209-0388
Mailing Address - Fax:252-209-0488
Practice Address - Street 1:228 MAIN ST E
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-3418
Practice Address - Country:US
Practice Address - Phone:252-209-0388
Practice Address - Fax:252-209-0488
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40789101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102193Medicaid