Provider Demographics
NPI:1376909390
Name:DAVIS, KEEGAN PATRICK
Entity Type:Individual
Prefix:MR
First Name:KEEGAN
Middle Name:PATRICK
Last Name:DAVIS
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 1:3769 W WATHEN AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-0853
Mailing Address - Country:US
Mailing Address - Phone:559-708-7704
Mailing Address - Fax:
Practice Address - Street 1:1945 N HELM AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-1670
Practice Address - Country:US
Practice Address - Phone:559-222-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1295972446Medicaid