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NPI Code Detail

MEDICARE: MR. KEITH LESLIE DERAAD CPRP

MEDICARE: MR. KEITH LESLIE DERAAD CPRP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1063532216
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. KEITH LESLIE DERAAD CPRP
Provider Business Mailing Address
First Line : 3700 W 83RD ST
Second Line :
City : BLOOMINGTON
State : MN
Zip : 55431-1063
Country : US
Telephone Number : 952-842-8273
Fax Number :
Provider Business Practice Location Address
First Line : 1825 CHICAGO AVE
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55404-1939
Country : US
Telephone Number : 612-752-8246
Fax Number : 612-752-8203
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/30/2007
Last Update Date : 07/08/2007

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