Provider Demographics
NPI:1326349994
Name:SOURS, KEITH
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:SOURS
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 1:103 MODESTO AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0414
Mailing Address - Country:US
Mailing Address - Phone:209-527-4597
Mailing Address - Fax:
Practice Address - Street 1:103 MODESTO AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0414
Practice Address - Country:US
Practice Address - Phone:209-527-4597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)