1518573633 NPI number — MR. KEEAN ANDREW KIRK MA, AMFT

Table of content: MR. KEEAN ANDREW KIRK MA, AMFT (NPI 1518573633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518573633 NPI number — MR. KEEAN ANDREW KIRK MA, AMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIRK
Provider First Name:
KEEAN
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA, AMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MENARD
Provider Other First Name:
KEEAN
Provider Other Middle Name:
ANDREW
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, AMFT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518573633
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26035 MOULTON PKWY APT 138
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92653-6246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-324-2622
Provider Business Mailing Address Fax Number:
949-452-0889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23461 S POINTE DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGUNA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92653-1523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-452-0888
Provider Business Practice Location Address Fax Number:
949-452-0889
Provider Enumeration Date:
09/23/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  AMFT108680 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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