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General NPI Number Information
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NPI Number | 1477169605
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Entity Type | Individual
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Provider Name | KEITH JOHN TANENBAUM LCSW
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Gender | Male
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Dates
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Enumeration Date | 09/22/2020
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Last Update Date | 10/05/2022
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Provider Practice Location Address
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Address Line | 924 EMERALD BAY RD FIRST FLOOR
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City | SOUTH LAKE TAHOE
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State | CA
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Zip | 96150
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Country | US
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Telephone | 530-782-9889
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Fax |
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Provider Business Mailing Address
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Address Line | 1362 US HIGHWAY 395 N STE 102-27
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City | GARDNERVILLE
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State | NV
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Zip | 89410-7306
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Country | US
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Telephone | 530-782-9889
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 89589
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2084H0002X
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Taxonomy Name | Hospice and Palliative Medicine (Psychiatry & Neurology) Physician
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License Number | 107074
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 107974
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License Number State | CA
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