Basic Information
| Provider Information | |||||||||
| NPI: | 1215359534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KECK | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.S., CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 999 S FAIRMONT AVE | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952405100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093338510 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3 MEDICAL PLAZA DR STE 220 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167737920 | ||||||||
| FaxNumber: | 9167737919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2014 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AU1094 | CA | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | AU1094 | 05 | CA | MEDICAID | AU1094 | 01 | CA | STATE LICENSE | OTHER |