Provider Demographics
NPI:1578953105
Name:KEEGAN, TYLER S
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:S
Last Name:KEEGAN
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 1:319 CEDARBROOK DRIVE
Mailing Address - Street 2:
Mailing Address - City:TWIN PEAKS
Mailing Address - State:CA
Mailing Address - Zip Code:92391
Mailing Address - Country:US
Mailing Address - Phone:800-967-6237
Mailing Address - Fax:
Practice Address - Street 1:319 CEDAR BROOK DRIVE
Practice Address - Street 2:
Practice Address - City:TWIN PEAKS
Practice Address - State:CA
Practice Address - Zip Code:92391
Practice Address - Country:US
Practice Address - Phone:800-967-6237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)