Provider Demographics
NPI:1295506467
Name:BROWN, KIESHA (NCLMBT# 13715)
Entity type:Individual
Prefix:
First Name:KIESHA
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:NCLMBT# 13715
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014B E GEER ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-5023
Mailing Address - Country:US
Mailing Address - Phone:919-599-8534
Mailing Address - Fax:
Practice Address - Street 1:5007 SOUTHPARK DR STE 130
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-7739
Practice Address - Country:US
Practice Address - Phone:919-572-2312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13715225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist