Basic Information
| Provider Information | |||||||||
| NPI: | 1457964843 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEITH | ||||||||
| FirstName: | MATELAND | ||||||||
| MiddleName: | LESTERY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | PMHNP-ABC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 421 COMMERCIAL CT STE B | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342921656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412444377 | ||||||||
| FaxNumber: | 9414454186 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 COMMERCIAL CT STE B | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342921656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412444377 | ||||||||
| FaxNumber: | 9414454186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2020 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | 28243714A | IN | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 363LP0808X | 11013737 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 163WA0400X | 28243714A | IN | N | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 163WP0807X | 28243714A | IN | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent | 163WP0808X | 28243714A | IN | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.