Provider Demographics
NPI:1609548643
Name:BACON, KIERA
Entity Type:Individual
Prefix:MRS
First Name:KIERA
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KIERA
Other - Middle Name:
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1395 EDEN RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-4101
Mailing Address - Country:US
Mailing Address - Phone:205-789-3100
Mailing Address - Fax:
Practice Address - Street 1:2025 PEACHTREE RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1413
Practice Address - Country:US
Practice Address - Phone:205-210-9297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW007266101YM0800X, 101YP2500X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty