Provider Demographics
NPI:1265899694
Name:PRINCE, KESHIA
Entity type:Individual
Prefix:
First Name:KESHIA
Middle Name:
Last Name:PRINCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 GEORGIA ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-5991
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:236 GEORGIA ST
Practice Address - Street 2:SUITE 102
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-5991
Practice Address - Country:US
Practice Address - Phone:888-544-5553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst