Basic Information
| Provider Information | |||||||||
| NPI: | 1245967611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKSON | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | RADT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1844 N ALTADENA DR | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911071047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267105989 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8140 SUNLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913523948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185828832 | ||||||||
| FaxNumber: | 8185828836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2022 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1445300921 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.