Provider Demographics
NPI:1639469257
Name:DRIEBERG, KEITH L (PHD)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:L
Last Name:DRIEBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 RIVERWALK PKWY
Mailing Address - Street 2:SOE-116
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503
Mailing Address - Country:US
Mailing Address - Phone:909-213-3010
Mailing Address - Fax:
Practice Address - Street 1:4500 RIVERWALK PKWY
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503
Practice Address - Country:US
Practice Address - Phone:909-213-3010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13844103G00000X, 103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent