Provider Demographics
NPI:1235874983
Name:PITTMAN, KEEGAN
Entity Type:Individual
Prefix:
First Name:KEEGAN
Middle Name:
Last Name:PITTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 WATSON CANYON CT APT 210
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-4995
Mailing Address - Country:US
Mailing Address - Phone:925-233-5195
Mailing Address - Fax:
Practice Address - Street 1:6904 VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-2406
Practice Address - Country:US
Practice Address - Phone:925-577-4732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA131098106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist