Provider Demographics
NPI:1770093452
Name:KEITH, COURTNEY TIERRA (LCSW 111075)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:TIERRA
Last Name:KEITH
Suffix:
Gender:F
Credentials:LCSW 111075
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 WAGNER ST UNIT 262
Mailing Address - Street 2:
Mailing Address - City:TROUTMAN
Mailing Address - State:NC
Mailing Address - Zip Code:28166-9627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5060 SHOREHAM PL STE 330
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5976
Practice Address - Country:US
Practice Address - Phone:619-866-0998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1110751041C0700X
OHS.15001301041C0700X
CA1200041041C0700X
NCC0136891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical