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General NPI Number Information
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NPI Number | 1063916872
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Entity Type | Individual
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Provider Name | KEITH LEE LARSEN CAADE-R
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Gender | Male
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Dates
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Enumeration Date | 03/19/2018
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Last Update Date | 03/19/2018
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Provider Practice Location Address
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Address Line | 1251 CALIFORNIA AVE STE 600
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City | PITTSBURG
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State | CA
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Zip | 94565-4145
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Country | US
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Telephone | 925-439-5161
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Fax | 925-439-0322
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Provider Business Mailing Address
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Address Line | 3016 MADISON CT
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City | ANTIOCH
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State | CA
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Zip | 94509-5333
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Country | US
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Telephone | 925-812-1233
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 11207-R
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License Number State | CA
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