Provider Demographics
NPI:1699386540
Name:KEITH, LIAM G
Entity Type:Individual
Prefix:
First Name:LIAM
Middle Name:G
Last Name:KEITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8915 SW CENTER ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6307
Mailing Address - Country:US
Mailing Address - Phone:503-726-3690
Mailing Address - Fax:
Practice Address - Street 1:4315 N GANTENBEIN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2905
Practice Address - Country:US
Practice Address - Phone:541-601-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health