Provider Demographics
NPI:1699967950
Name:MCGILL, KEISHA K (MA)
Entity type:Individual
Prefix:MRS
First Name:KEISHA
Middle Name:K
Last Name:MCGILL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E LAKEWOOD AVE STE E
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-1700
Mailing Address - Country:US
Mailing Address - Phone:919-286-2146
Mailing Address - Fax:919-908-6787
Practice Address - Street 1:401 E LAKEWOOD AVE STE E
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-1700
Practice Address - Country:US
Practice Address - Phone:919-286-2146
Practice Address - Fax:919-908-6787
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6486101YM0800X
IN39001713A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103673Medicaid