Provider Demographics
NPI:1669933719
Name:HAPPAWANA, KEITH
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:HAPPAWANA
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 1:5955 ZEAMER AVE # 673MDG
Mailing Address - Street 2:
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506-3702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-1122
Practice Address - Country:US
Practice Address - Phone:513-273-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA7296103TC0700X
AK180102103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
00OtherMILITARY