Provider Demographics
NPI:1639866494
Name:CASTERLOW, KEOTIA EVETTE SMITHERMAN (LCMHCA)
Entity Type:Individual
Prefix:
First Name:KEOTIA
Middle Name:EVETTE SMITHERMAN
Last Name:CASTERLOW
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:KEOTIA
Other - Middle Name:EVETTE
Other - Last Name:SMITHERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1592 CANDACE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8595
Mailing Address - Country:US
Mailing Address - Phone:336-509-7616
Mailing Address - Fax:
Practice Address - Street 1:250 EXECUTIVE PARK BLVD STE 120
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1534
Practice Address - Country:US
Practice Address - Phone:336-509-7616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18588101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health