Provider Demographics
NPI:1003372616
Name:LE, KEVEN
Entity type:Individual
Prefix:
First Name:KEVEN
Middle Name:
Last Name:LE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CONCORD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4969
Mailing Address - Country:US
Mailing Address - Phone:510-268-8120
Mailing Address - Fax:
Practice Address - Street 1:1700 S AMPHLETT BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2717
Practice Address - Country:US
Practice Address - Phone:650-507-3193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 247200000X
CA172V00000X
CAMPSS-DEROMN175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other