Healthcare Provider Details

I. General information

NPI: 1922002971
Provider Name (Legal Business Name): KEITH ELLIOT KERNS MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 FAIRVIEW LN STE K
SONORA CA
95370-4828
US

IV. Provider business mailing address

PO BOX 4386
SONORA CA
95370-1386
US

V. Phone/Fax

Practice location:
  • Phone: 209-586-2249
  • Fax: 209-586-2249
Mailing address:
  • Phone: 209-586-2249
  • Fax: 209-586-2249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 23993
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: