Basic Information
| Provider Information | |||||||||
| NPI: | 1780744995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELAERE | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | JEROME | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4785 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937260513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594485251 | ||||||||
| FaxNumber: | 5594484950 | ||||||||
| Practice Location | |||||||||
| Address1: | 4785 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937260513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594485251 | ||||||||
| FaxNumber: | 5594484950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS 17721 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.