Healthcare Provider Details

I. General information

NPI: 1669933719
Provider Name (Legal Business Name): DR. KEITH HAPPAWANA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WAYNE AVE
DAYTON OH
45410-1122
US

IV. Provider business mailing address

5955 ZEAMER AVE # 673MDG
JBER AK
99506-3702
US

V. Phone/Fax

Practice location:
  • Phone: 513-273-1140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7296
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number180102
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: