Provider Demographics
NPI:1811178445
Name:KEITH C. WARREN, PH.D., P.C.
Entity type:Organization
Organization Name:KEITH C. WARREN, PH.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:C
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:254-722-9961
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23289103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00D59RMedicare PIN