Basic Information
| Provider Information | |||||||||
| NPI: | 1083070536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KECK | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD EXECUTIVE PLAZA 1 | ||||||||
| Address2: | STE 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037384331 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1630 WILKES RIDGE PKWY | ||||||||
| Address2: | STE 105 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232337460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042707262 | ||||||||
| FaxNumber: | 8042707264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2016 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 0810005353 | VA | Y | Behavioral Health & Social Service Providers | Psychologist | 103TH0004X | 0810005353 | VA | N | Behavioral Health & Social Service Providers | Psychologist | Health |
No ID Information.