Provider Demographics
NPI:1114101763
Name:VIELLE, KEITH HARDRICK (SUDCC 6465)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:HARDRICK
Last Name:VIELLE
Suffix:
Gender:M
Credentials:SUDCC 6465
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17707 STUDEBAKER RD
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2640
Mailing Address - Country:US
Mailing Address - Phone:562-402-0677
Mailing Address - Fax:
Practice Address - Street 1:17707 STUDEBAKER RD
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2640
Practice Address - Country:US
Practice Address - Phone:562-402-0677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA104185101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker