Provider Demographics
NPI:1770346330
Name:CARR, KEITWEN MONIQUE
Entity type:Individual
Prefix:
First Name:KEITWEN
Middle Name:MONIQUE
Last Name:CARR
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 W MOSS AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1642
Mailing Address - Country:US
Mailing Address - Phone:623-237-1546
Mailing Address - Fax:
Practice Address - Street 1:1848 WILLOW PASS RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2591
Practice Address - Country:US
Practice Address - Phone:916-204-6296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAC1501416101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health