Provider Demographics
NPI:1942216148
Name:HERSH, KEITH RICHARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:RICHARD
Last Name:HERSH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 WEST HIGHWAY 54
Mailing Address - Street 2:SUITE 111
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707
Mailing Address - Country:US
Mailing Address - Phone:919-419-0524
Mailing Address - Fax:919-419-9651
Practice Address - Street 1:1415 WEST HIGHWAY 54
Practice Address - Street 2:SUITE 111
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707
Practice Address - Country:US
Practice Address - Phone:919-419-0524
Practice Address - Fax:919-419-9651
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2693103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000480Medicaid