Provider Demographics
NPI:1851713754
Name:STETSON, KEITH (LAC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:STETSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1502 WALNUT ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1563
Mailing Address - Country:US
Mailing Address - Phone:510-859-4595
Mailing Address - Fax:510-280-1629
Practice Address - Street 1:1502 WALNUT ST
Practice Address - Street 2:SUITE A
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1563
Practice Address - Country:US
Practice Address - Phone:510-859-4595
Practice Address - Fax:510-280-1629
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC4193171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist