Provider Demographics
NPI:1760718753
Name:WESTON, KEIAUNTAE L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KEIAUNTAE
Middle Name:L
Last Name:WESTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6439 GARNERS FERRY RD
Mailing Address - Street 2:#122
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1638
Mailing Address - Country:US
Mailing Address - Phone:803-776-4000
Mailing Address - Fax:803-695-7932
Practice Address - Street 1:6439 GARNERS FERRY RD
Practice Address - Street 2:#122
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1638
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:803-695-7932
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0041761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2010Medicare PIN
GA000606317BMedicaid