Provider Demographics
NPI:1770047805
Name:MARSHALL, KEANTE
Entity Type:Individual
Prefix:
First Name:KEANTE
Middle Name:
Last Name:MARSHALL
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 1:3031 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-3033
Mailing Address - Country:US
Mailing Address - Phone:323-766-2345
Mailing Address - Fax:
Practice Address - Street 1:3031 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-3033
Practice Address - Country:US
Practice Address - Phone:323-373-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician