Provider Demographics
NPI:1023455789
Name:KEITH, DWAYNE ROOSEVELT
Entity type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:ROOSEVELT
Last Name:KEITH
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 1:314 W MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90220-2104
Mailing Address - Country:US
Mailing Address - Phone:310-531-4963
Mailing Address - Fax:
Practice Address - Street 1:314 W MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-2104
Practice Address - Country:US
Practice Address - Phone:310-531-4963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor