Provider Demographics
NPI:1447926811
Name:KEO, SOKDINA
Entity type:Individual
Prefix:
First Name:SOKDINA
Middle Name:
Last Name:KEO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21935 VAN BUREN ST STE A1
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5652
Mailing Address - Country:US
Mailing Address - Phone:909-906-1023
Mailing Address - Fax:909-906-1032
Practice Address - Street 1:21935 VAN BUREN ST STE A1
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5652
Practice Address - Country:US
Practice Address - Phone:909-906-1023
Practice Address - Fax:909-906-1032
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11877101YP2500X
CA133644106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional