Provider Demographics
NPI:1063916872
Name:LARSEN, KEITH LEE (CAADE-R)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:LEE
Last Name:LARSEN
Suffix:
Gender:M
Credentials:CAADE-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 MADISON CT
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-5333
Mailing Address - Country:US
Mailing Address - Phone:925-812-1233
Mailing Address - Fax:
Practice Address - Street 1:1251 CALIFORNIA AVE STE 600
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-4145
Practice Address - Country:US
Practice Address - Phone:925-439-5161
Practice Address - Fax:925-439-0322
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11207-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)