Provider Demographics
NPI:1033691282
Name:LIBBRECHT, KEISHA M
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:M
Last Name:LIBBRECHT
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 1:3405 VETERAN AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-5341
Mailing Address - Country:US
Mailing Address - Phone:209-505-1656
Mailing Address - Fax:
Practice Address - Street 1:3405 VETERAN AVE APT 4
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-5341
Practice Address - Country:US
Practice Address - Phone:209-505-1656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA119480106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist