Provider Demographics
NPI:1235704412
Name:NELSON-BARER, KEENAN MATTHEW
Entity Type:Individual
Prefix:MR
First Name:KEENAN
Middle Name:MATTHEW
Last Name:NELSON-BARER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KEENAN
Other - Middle Name:MATTHEW
Other - Last Name:NELSON-BARER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:KEENAN NELSON-BARER
Mailing Address - Street 1:2135 ESSEX ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1814
Mailing Address - Country:US
Mailing Address - Phone:510-604-4405
Mailing Address - Fax:
Practice Address - Street 1:3800 COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-3399
Practice Address - Country:US
Practice Address - Phone:510-482-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132101106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty