Provider Demographics
NPI:1669604120
Name:KEITH, CLIFFORD
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:
Last Name:KEITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 E ALBERTONI ST
Mailing Address - Street 2:#109
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-1539
Mailing Address - Country:US
Mailing Address - Phone:213-820-1511
Mailing Address - Fax:310-626-9754
Practice Address - Street 1:637 E ALBERTONI ST
Practice Address - Street 2:#109
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-1539
Practice Address - Country:US
Practice Address - Phone:213-820-1511
Practice Address - Fax:310-626-9754
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190600AP101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor