Basic Information
| Provider Information | |||||||||
| NPI: | 1457300774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NUNN | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 WILLOW LN | ||||||||
| Address2: | |||||||||
| City: | NORTH WILKESBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286593551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366675151 | ||||||||
| FaxNumber: | 3368383133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2006 | ||||||||
| LastUpdateDate: | 06/07/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5221 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 6103158 | 05 | NC | MEDICAID | 1413X | 01 | NC | BLUECROSS BLUESHIELD OF N | OTHER |