Provider Demographics
NPI:1619376803
Name:HART, KEEGAN
Entity Type:Individual
Prefix:
First Name:KEEGAN
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18802 MANDAN ST
Mailing Address - Street 2:UNIT #901
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91351-3716
Mailing Address - Country:US
Mailing Address - Phone:818-261-5580
Mailing Address - Fax:661-367-7778
Practice Address - Street 1:18802 MANDAN ST
Practice Address - Street 2:UNIT #901
Practice Address - City:CANYON COUNTRY
Practice Address - State:CA
Practice Address - Zip Code:91351-3716
Practice Address - Country:US
Practice Address - Phone:818-261-5580
Practice Address - Fax:661-367-7778
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-15-18352103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst