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General NPI Number Information
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NPI Number | 1356476782
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Entity Type | Individual
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Provider Name | KEITH RICHARD KOKSENG PSY. D.
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Gender | Male
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Dates
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Enumeration Date | 02/23/2007
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Last Update Date | 06/22/2022
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Provider Practice Location Address
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Address Line | 2804 1ST AVE S
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City | SAINT PETERSBURG
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State | FL
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Zip | 33712-1002
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Country | US
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Telephone | 813-523-7563
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Fax |
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Provider Business Mailing Address
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Address Line | 2804 1ST AVE S
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City | SAINT PETERSBURG
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State | FL
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Zip | 33712-1002
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Country | US
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Telephone | 727-201-2485
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Fax | 813-272-3766
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY9814
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License Number State | FL
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