Provider Demographics
NPI:1174836951
Name:STAR, KEITH IAN
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:IAN
Last Name:STAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KEITH
Other - Middle Name:
Other - Last Name:STAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:18646 OXNARD ST
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-1411
Mailing Address - Country:US
Mailing Address - Phone:818-996-1051
Mailing Address - Fax:
Practice Address - Street 1:18646 OXNARD ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-1411
Practice Address - Country:US
Practice Address - Phone:818-996-1051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC28743106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist