Healthcare Provider Details

I. General information

NPI: 1831450840
Provider Name (Legal Business Name): KEISHA LYN LORD LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KEISHA LYN CASS LMFT

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 09/13/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE STE 2002
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

4560 HALLMARK PKWY UNIT 9095
SAN BERNARDINO CA
92427-6005
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-7320
  • Fax: 951-955-7203
Mailing address:
  • Phone: 909-487-5525
  • Fax: 909-232-9073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT106359
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: