Provider Demographics
NPI:1477569168
Name:HERGENHAHN, KEITH FITZGERALD (LCSW)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:FITZGERALD
Last Name:HERGENHAHN
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 1:5750 BALCONES DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4252
Mailing Address - Country:US
Mailing Address - Phone:512-472-4009
Mailing Address - Fax:512-472-4009
Practice Address - Street 1:5750 BALCONES DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4252
Practice Address - Country:US
Practice Address - Phone:512-472-4009
Practice Address - Fax:512-472-4009
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27659101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional