Provider Demographics
NPI:1275558694
Name:ANDERSEN, KEITH J (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:J
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:PHD
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 873
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93515-0873
Mailing Address - Country:US
Mailing Address - Phone:760-873-6712
Mailing Address - Fax:760-873-6712
Practice Address - Street 1:152 PIONEER LN STE H
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2563
Practice Address - Country:US
Practice Address - Phone:760-873-6712
Practice Address - Fax:760-873-6712
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14114103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral