Provider Demographics
NPI:1457973679
Name:MCLEAN, KIESHA
Entity Type:Individual
Prefix:
First Name:KIESHA
Middle Name:
Last Name:MCLEAN
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 1:191 GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2831
Mailing Address - Country:US
Mailing Address - Phone:912-332-7920
Mailing Address - Fax:
Practice Address - Street 1:4359 KUKUI GROVE ST STE 102
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-2008
Practice Address - Country:US
Practice Address - Phone:916-337-4052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician