Provider Demographics
NPI:1891380119
Name:KEESECKER, EDITH COWAN (LCMHC-A)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:COWAN
Last Name:KEESECKER
Suffix:
Gender:F
Credentials:LCMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 NC HIGHWAY 306 N
Mailing Address - Street 2:
Mailing Address - City:GRANTSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28529-5873
Mailing Address - Country:US
Mailing Address - Phone:304-997-5417
Mailing Address - Fax:
Practice Address - Street 1:2407 GRACE AVE # 20
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-4416
Practice Address - Country:US
Practice Address - Phone:252-670-5637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16393101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health