Provider Demographics
NPI:1588806335
Name:HABERSTOCK, KEITH ROBERT (MS, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ROBERT
Last Name:HABERSTOCK
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2178 MARSHALL WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-3544
Mailing Address - Country:US
Mailing Address - Phone:916-452-0407
Mailing Address - Fax:
Practice Address - Street 1:96 W MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-3016
Practice Address - Country:US
Practice Address - Phone:530-668-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13741235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist