Provider Demographics
NPI:1225162282
Name:MALLEY, KEITH (MFT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:MALLEY
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:PO BOX 662
Mailing Address - Street 2:
Mailing Address - City:NORTH SAN JUAN
Mailing Address - State:CA
Mailing Address - Zip Code:95960-0662
Mailing Address - Country:US
Mailing Address - Phone:530-292-1732
Mailing Address - Fax:530-292-1732
Practice Address - Street 1:18688 SAGES RD
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-9374
Practice Address - Country:US
Practice Address - Phone:530-292-1732
Practice Address - Fax:530-292-1732
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC34873106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist