Provider Demographics
NPI:1306378401
Name:HALL, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:HALL
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 1:1430 WILLOW PASS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-7946
Mailing Address - Country:US
Mailing Address - Phone:925-348-5439
Mailing Address - Fax:925-646-5774
Practice Address - Street 1:1430 WILLOW PASS RD STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-7946
Practice Address - Country:US
Practice Address - Phone:925-348-5439
Practice Address - Fax:925-646-5774
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
373H00000X, 101YM0800X, 172V00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC5650646OtherCA DRIVERS LICENSE