Provider Demographics
NPI:1205439676
Name:MCDANIELS, KEAYERA
Entity type:Individual
Prefix:
First Name:KEAYERA
Middle Name:
Last Name:MCDANIELS
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 1:3870 CRENSHAW BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-1815
Mailing Address - Country:US
Mailing Address - Phone:323-290-5058
Mailing Address - Fax:
Practice Address - Street 1:3870 CRENSHAW BLVD STE 212
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-1815
Practice Address - Country:US
Practice Address - Phone:323-290-5058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122340106H00000X
CA143724106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist