Provider Demographics
NPI:1881129625
Name:REDDISH, KEENAN (LMFT)
Entity type:Individual
Prefix:MR
First Name:KEENAN
Middle Name:
Last Name:REDDISH
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8306 OFFICE PARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-6935
Mailing Address - Country:US
Mailing Address - Phone:470-485-2987
Mailing Address - Fax:678-391-8275
Practice Address - Street 1:8306 OFFICE PARK DR STE B
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-6935
Practice Address - Country:US
Practice Address - Phone:470-485-2987
Practice Address - Fax:678-391-8275
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001332106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist