Provider Demographics
NPI:1063532216
Name:DERAAD, KEITH LESLIE (CPRP)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:LESLIE
Last Name:DERAAD
Suffix:
Gender:M
Credentials:CPRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 W 83RD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1063
Mailing Address - Country:US
Mailing Address - Phone:952-842-8273
Mailing Address - Fax:
Practice Address - Street 1:1825 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1939
Practice Address - Country:US
Practice Address - Phone:612-752-8246
Practice Address - Fax:612-752-8203
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health