Provider Demographics
NPI:1336641190
Name:CROWNER, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:CROWNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:HERU-KA
Other - Middle Name:
Other - Last Name:ANU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PWS
Mailing Address - Street 1:8428 N BLISS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-1177
Mailing Address - Country:US
Mailing Address - Phone:443-453-3010
Mailing Address - Fax:
Practice Address - Street 1:8428 N BLISS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-1177
Practice Address - Country:US
Practice Address - Phone:443-453-3010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No172V00000XOther Service ProvidersCommunity Health Worker