Provider Demographics
NPI:1841501756
Name:REDFEARN, KEYONNE
Entity type:Individual
Prefix:
First Name:KEYONNE
Middle Name:
Last Name:REDFEARN
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 1:8823 TIBER ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-3105
Mailing Address - Country:US
Mailing Address - Phone:805-383-3669
Mailing Address - Fax:805-383-3692
Practice Address - Street 1:1756 S LEWIS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8520
Practice Address - Country:US
Practice Address - Phone:805-383-3669
Practice Address - Fax:805-383-3692
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA174400000XOtherOTHER