Provider Demographics
NPI:1023577376
Name:LOMOTEY, KEILAH
Entity Type:Individual
Prefix:
First Name:KEILAH
Middle Name:
Last Name:LOMOTEY
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 1:1742 XIMENO AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-3754
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1742 XIMENO AVE APT 9
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-3754
Practice Address - Country:US
Practice Address - Phone:562-313-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-17
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA96204980AMedicaid
CAAJC908765300Medicaid