Provider Demographics
NPI:1205608270
Name:KEITH, CHRISNICOLAS PAUL
Entity type:Individual
Prefix:
First Name:CHRISNICOLAS
Middle Name:PAUL
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 1:234 W BANDERA RD # 325
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-2805
Mailing Address - Country:US
Mailing Address - Phone:210-447-7041
Mailing Address - Fax:866-403-7980
Practice Address - Street 1:2525 LADD ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78236-5308
Practice Address - Country:US
Practice Address - Phone:210-447-7041
Practice Address - Fax:866-403-7980
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23-4210-619985106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician