Provider Demographics
NPI:1851059885
Name:GAUSE, KEYANA
Entity Type:Individual
Prefix:MS
First Name:KEYANA
Middle Name:
Last Name:GAUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7048 KNIGHTDALE BLVD STE 220C
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-8894
Mailing Address - Country:US
Mailing Address - Phone:919-944-3130
Mailing Address - Fax:
Practice Address - Street 1:7048 KNIGHTDALE BLVD STE 220C
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-8894
Practice Address - Country:US
Practice Address - Phone:919-944-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP016769104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC376241Medicaid