Provider Demographics
NPI:1790412765
Name:BREEDEN, KEON DEVONTE (LCSWA)
Entity Type:Individual
Prefix:MR
First Name:KEON
Middle Name:DEVONTE
Last Name:BREEDEN
Suffix:
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 MORTON ST APT 223
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5340
Mailing Address - Country:US
Mailing Address - Phone:704-386-8651
Mailing Address - Fax:
Practice Address - Street 1:933 LOUISE AVE STE 10117
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-0053
Practice Address - Country:US
Practice Address - Phone:704-226-2282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0168421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty