Provider Demographics
NPI:1023267804
Name:MARSHALL, KEISHA (MFT INTERN)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9047 ARROW RTE
Mailing Address - Street 2:SUITE 170
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4449
Mailing Address - Country:US
Mailing Address - Phone:909-466-8696
Mailing Address - Fax:
Practice Address - Street 1:9047 ARROW RTE
Practice Address - Street 2:SUITE 170
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4449
Practice Address - Country:US
Practice Address - Phone:909-466-8696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 52798106H00000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist