Provider Demographics
NPI:1679004527
Name:KEITH, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:KEITH
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 1:332 BANDINI PL
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-5903
Mailing Address - Country:US
Mailing Address - Phone:760-525-9972
Mailing Address - Fax:
Practice Address - Street 1:707 CIVIC CENTER DR
Practice Address - Street 2:SUITE 106
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-6160
Practice Address - Country:US
Practice Address - Phone:760-618-1552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96884106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist