Provider Demographics
NPI:1235845496
Name:PRIDGEON, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:PRIDGEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CHAUN
Other - Middle Name:
Other - Last Name:PRIDGEON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:354 MERRIMACK ST STE 395
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1755
Mailing Address - Country:US
Mailing Address - Phone:774-206-1125
Mailing Address - Fax:774-628-9657
Practice Address - Street 1:2600 S MICHIGAN AVE STE 104
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2857
Practice Address - Country:US
Practice Address - Phone:774-206-1125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor