Provider Demographics
NPI:1194081372
Name:LAWRENCE, KEITH
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-3018
Mailing Address - Country:US
Mailing Address - Phone:562-743-3117
Mailing Address - Fax:
Practice Address - Street 1:35 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-3018
Practice Address - Country:US
Practice Address - Phone:562-743-3117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50919106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist