Healthcare Provider Details

I. General information

NPI: 1407634660
Provider Name (Legal Business Name): KEVIN KENNETH KEERAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5051 CANYON CREST DR STE 204
RIVERSIDE CA
92507-6035
US

IV. Provider business mailing address

41760 IVY ST STE 204
MURRIETA CA
92562-9416
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-1488
  • Fax:
Mailing address:
  • Phone: 951-698-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSB94027773
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: