Provider Demographics
NPI:1659443737
Name:KEYSON, MAE TESTER (PHD)
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:TESTER
Last Name:KEYSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22817 VENTURA BLVD # 499
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-1202
Mailing Address - Country:US
Mailing Address - Phone:818-225-2222
Mailing Address - Fax:
Practice Address - Street 1:15300 VENTURA BLVD
Practice Address - Street 2:SUITE 520A
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3103
Practice Address - Country:US
Practice Address - Phone:818-225-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4911103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP4911AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NO.