Provider Demographics
NPI:1477169605
Name:TANENBAUM, KEITH JOHN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:JOHN
Last Name:TANENBAUM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1362 US HIGHWAY 395 N STE 102-27
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89410-7306
Mailing Address - Country:US
Mailing Address - Phone:530-782-9889
Mailing Address - Fax:
Practice Address - Street 1:924 EMERALD BAY RD
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:530-782-9889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89589101YM0800X
CA1070742084H0002X
CA1079741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No2084H0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyHospice and Palliative Medicine