Provider Demographics
NPI:1447673637
Name:HORNBECK, KEEGAN JOHN (LCSW)
Entity type:Individual
Prefix:MR
First Name:KEEGAN
Middle Name:JOHN
Last Name:HORNBECK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3928 LA SALLE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-1161
Mailing Address - Country:US
Mailing Address - Phone:323-383-5526
Mailing Address - Fax:
Practice Address - Street 1:12240 VENICE BLVD STE 15A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066
Practice Address - Country:US
Practice Address - Phone:310-751-5344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-24
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA819541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program