Provider Demographics
NPI:1518063494
Name:KILBURN, KEITH PARLEY (MFT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:PARLEY
Last Name:KILBURN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 SKILLMAN LN
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952
Mailing Address - Country:US
Mailing Address - Phone:707-762-4338
Mailing Address - Fax:707-776-0935
Practice Address - Street 1:25 WESTERN AV
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952
Practice Address - Country:US
Practice Address - Phone:707-526-8306
Practice Address - Fax:707-776-0935
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC32587106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist