Provider Demographics
NPI:1932235322
Name:BROOKS-BACOTE, KEISA AYANA
Entity type:Individual
Prefix:
First Name:KEISA
Middle Name:AYANA
Last Name:BROOKS-BACOTE
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 1:431 EDGAR CIR
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-1600
Mailing Address - Country:US
Mailing Address - Phone:864-554-1453
Mailing Address - Fax:
Practice Address - Street 1:431 EDGAR CIR
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-1600
Practice Address - Country:US
Practice Address - Phone:864-554-1453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
GALPC008161101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health