Provider Demographics
NPI:1649356031
Name:WARREN, KEITH CLEMENTS (PH D)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:CLEMENTS
Last Name:WARREN
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5020 LAKELAND CIR
Mailing Address - Street 2:SUITE B
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2996
Mailing Address - Country:US
Mailing Address - Phone:254-722-9961
Mailing Address - Fax:254-399-9290
Practice Address - Street 1:5020 LAKELAND CIR
Practice Address - Street 2:SUITE B
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2996
Practice Address - Country:US
Practice Address - Phone:254-722-9961
Practice Address - Fax:254-399-9290
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23289103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX039240902Medicaid
TX00D59ROtherBCBS
TX00D59RMedicare PIN