Provider Demographics
NPI:1932959186
Name:REID, KEITA CYBELE (PPS)
Entity Type:Individual
Prefix:MS
First Name:KEITA
Middle Name:CYBELE
Last Name:REID
Suffix:
Gender:F
Credentials:PPS
Other - Prefix:
Other - First Name:KEITA
Other - Middle Name:CYBELE
Other - Last Name:MARNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PPS
Mailing Address - Street 1:PO BOX 4526
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93921-4526
Mailing Address - Country:US
Mailing Address - Phone:831-250-3572
Mailing Address - Fax:
Practice Address - Street 1:2121 IMOLA AVE
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-3625
Practice Address - Country:US
Practice Address - Phone:707-253-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool