Keith Park
Individual provider Active NPI Counselor · Calimesa, CA
NPI 1710101092 · NPPES record last updated Sep 11, 2025
Key facts
- NPI
- 1710101092
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Counselor 101Y00000X
- License
- 0085201 (NM)
- Practice address
- 908 Park Ave
Calimesa, CA 92320-1148 - Phone
- (909) 518-3886
- Fax
- (909) 790-9333
- NPI assigned
- Apr 11, 2007
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0085201 | NM | MD | Counselor |
| PSY 18884 | CA | MD | Psychologist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Counselor | 101Y00000X | 0085201 | NM | Yes |
| Psychologist | 103T00000X | PSY 18884 | CA |
Addresses
Primary practice location
908 Park Ave
Calimesa, CA 92320-1148
Mailing address
PO Box 1526
Yucaipa, CA 92399-1435
Phone (909) 518-3886
Other providers in Calimesa, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 11, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.