MEDICARE: MR. KEITH MALLEY MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC34873	CA

General Provider Information

NPI Number	:	1225162282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEITH MALLEY MFT

Provider Business Mailing Address
First Line	:	PO BOX 662
Second Line	:
City	:	NORTH SAN JUAN
State	:	CA
Zip	:	95960-0662
Country	:	US
Telephone Number	:	530-292-1732
Fax Number	:	530-292-1732

Provider Business Practice Location Address
First Line	:	18688 SAGES RD
Second Line	:
City	:	NEVADA CITY
State	:	CA
Zip	:	95959-9374
Country	:	US
Telephone Number	:	530-292-1732
Fax Number	:	530-292-1732

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	04/04/2013

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