Basic Information
| Provider Information | |||||||||
| NPI: | 1023558293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEITH | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
| Credential: | LCDC III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5982 RHODES RD | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442408100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306731347 | ||||||||
| FaxNumber: | 3306783677 | ||||||||
| Practice Location | |||||||||
| Address1: | 799 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192292222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2017 | ||||||||
| LastUpdateDate: | 06/14/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 161333 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.