Provider Demographics
NPI:1164636056
Name:EDWARDS, KEITH JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:JOHN
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 GOTERA DR
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6613
Mailing Address - Country:US
Mailing Address - Phone:626-968-7075
Mailing Address - Fax:562-903-4864
Practice Address - Street 1:12625 LA MIRADA BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-2211
Practice Address - Country:US
Practice Address - Phone:562-903-4800
Practice Address - Fax:562-903-4802
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10082103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical