Provider Demographics
NPI:1710101092
Name:PARK, KEITH
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:PARK
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:PO BOX 1526
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-1435
Mailing Address - Country:US
Mailing Address - Phone:909-518-3886
Mailing Address - Fax:909-790-9333
Practice Address - Street 1:908 PARK AVE
Practice Address - Street 2:
Practice Address - City:CALIMESA
Practice Address - State:CA
Practice Address - Zip Code:92320-1148
Practice Address - Country:US
Practice Address - Phone:909-518-3886
Practice Address - Fax:909-790-9333
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0085201101Y00000X
CAPSY 18884103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist