Healthcare Provider Details

I. General information

NPI: 1992539282
Provider Name (Legal Business Name): KEYON ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N RAYMOND AVE STE 602
PASADENA CA
91103-4443
US

IV. Provider business mailing address

11058 CHANDLER BLVD APT 1009E
NORTH HOLLYWOOD CA
91601-4176
US

V. Phone/Fax

Practice location:
  • Phone: 562-283-5986
  • Fax:
Mailing address:
  • Phone: 562-283-5986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number123826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: