Provider Demographics
NPI:1245967611
Name:DICKSON, KEITH ROBERT (RADT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ROBERT
Last Name:DICKSON
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1844 N ALTADENA DR
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1047
Mailing Address - Country:US
Mailing Address - Phone:626-710-5989
Mailing Address - Fax:
Practice Address - Street 1:8140 SUNLAND BLVD
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-3948
Practice Address - Country:US
Practice Address - Phone:818-582-8832
Practice Address - Fax:818-582-8836
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1445300921101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)