Provider Demographics
NPI:1740449610
Name:BLACKSHEAR, KEISHA (LMFT)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:BLACKSHEAR
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 S NELSON ST APT 23
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-1436
Mailing Address - Country:US
Mailing Address - Phone:626-833-2588
Mailing Address - Fax:
Practice Address - Street 1:205 PASADENA AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2919
Practice Address - Country:US
Practice Address - Phone:323-344-5536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90418106H00000X
CALMFT90418106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7184OtherMEDI-CAL
CA7708OtherMEDI-CAL
CA7368OtherMEDI-CAL
CA7667OtherMEDI-CAL