Provider Demographics
NPI:1073617361
Name:KEOUGH, KENNETH ROBERT (MFT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
Last Name:KEOUGH
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-2478
Mailing Address - Country:US
Mailing Address - Phone:415-531-4846
Mailing Address - Fax:510-595-1134
Practice Address - Street 1:876 43RD ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94608-3714
Practice Address - Country:US
Practice Address - Phone:415-531-4846
Practice Address - Fax:510-595-1134
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46870106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist