Provider Demographics
NPI:1922376771
Name:MARTIN, KEITH ERIC (MSW)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ERIC
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2491 PURDUE AVE.
Mailing Address - Street 2:#213
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-5119
Mailing Address - Country:US
Mailing Address - Phone:310-927-0199
Mailing Address - Fax:
Practice Address - Street 1:2491 PURDUE AVE
Practice Address - Street 2:213
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-3046
Practice Address - Country:US
Practice Address - Phone:310-927-0199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical