Provider Demographics
NPI:1679768162
Name:KEDDY, PHILIP JAMES (PHD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:JAMES
Last Name:KEDDY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 COLLEGE AVE
Mailing Address - Street 2:216
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1585
Mailing Address - Country:US
Mailing Address - Phone:510-655-8824
Mailing Address - Fax:510-845-6889
Practice Address - Street 1:5625 COLLEGE AVE
Practice Address - Street 2:216
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1585
Practice Address - Country:US
Practice Address - Phone:510-655-8824
Practice Address - Fax:510-845-6889
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-08
Last Update Date:2007-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8828103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY8828OtherPSYCHOLOGIST LICENSE
CA00PL88280Medicare UPIN