Provider Demographics
NPI:1720368822
Name:KEYSTONE COMMUNITY PARTNERS, INC.
Entity Type:Organization
Organization Name:KEYSTONE COMMUNITY PARTNERS, INC.
Other - Org Name:KEYSTONE COMMUNITY PARTNERS, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ORGANIZATION ORGANIZER
Authorized Official - Prefix:MS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LCAS-A
Authorized Official - Phone:919-522-2508
Mailing Address - Street 1:3656 ROGERS RD
Mailing Address - Street 2:SUITE 177
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-9306
Mailing Address - Country:US
Mailing Address - Phone:919-832-1011
Mailing Address - Fax:
Practice Address - Street 1:2321 CRABTREE BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1567
Practice Address - Country:US
Practice Address - Phone:919-522-2508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008615Medicaid
NC5920611Medicaid