Basic Information
Provider Information | |||||||||
NPI: | 1518012681 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KEITZ | ||||||||
FirstName: | TIFFANY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | S.L.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2615 E RANDOLPH AVE STE AND113 | ||||||||
Address2: |   | ||||||||
City: | ENID | ||||||||
State: | OK | ||||||||
PostalCode: | 737014670 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5802318081 | ||||||||
FaxNumber: | 5802342615 | ||||||||
Practice Location | |||||||||
Address1: | 2615 E RANDOLPH AVE STE AND113 | ||||||||
Address2: |   | ||||||||
City: | ENID | ||||||||
State: | OK | ||||||||
PostalCode: | 737014670 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5802318081 | ||||||||
FaxNumber: | 4052545531 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2007 | ||||||||
LastUpdateDate: | 03/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3182 | OK | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 200125650B | 05 | OK |   | MEDICAID |