Provider Demographics
NPI:1043344070
Name:KEITH, DONNA (IMFT)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:IMFT
Other - Prefix:
Other - First Name:YASHA
Other - Middle Name:
Other - Last Name:KEITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IMFT
Mailing Address - Street 1:15887 NORVIN WAY
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95949-7035
Mailing Address - Country:US
Mailing Address - Phone:530-277-8621
Mailing Address - Fax:
Practice Address - Street 1:500 CROWN POINT CIR STE 120
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9514
Practice Address - Country:US
Practice Address - Phone:530-265-5811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74853106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist