Provider Demographics
NPI:1003390790
Name:WARREN, KEITH L SR (CDCA II)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:L
Last Name:WARREN
Suffix:SR
Gender:M
Credentials:CDCA II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 WATERTOWER DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-5983
Mailing Address - Country:US
Mailing Address - Phone:614-668-1063
Mailing Address - Fax:
Practice Address - Street 1:7400 HUNTINGTON DR
Practice Address - Street 2:7400 HUNTINGTON DR
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235
Practice Address - Country:US
Practice Address - Phone:614-505-0378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161965101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)