Basic Information
| Provider Information | |||||||||
| NPI: | 1700294071 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TIFFANY KEITZ SPEECH PATHOLOGY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2615 E RANDOLPH | ||||||||
| Address2: | STE 112 | ||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737014670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802318081 | ||||||||
| FaxNumber: | 5802342615 | ||||||||
| Practice Location | |||||||||
| Address1: | 2615 E RANDOLPH | ||||||||
| Address2: | STE 112 | ||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737014670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802318081 | ||||||||
| FaxNumber: | 5802342615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2014 | ||||||||
| LastUpdateDate: | 05/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | KEITZ | ||||||||
| AuthorizedOfficialFirstName: | TIFFANY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 5802318081 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MS CCC SLP | ||||||||
| NPICertificationDate: | 05/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3182 | OK | N | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 261QH0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech |
ID Information
| ID | Type | State | Issuer | Description | 200125650B | 05 | OK | MEDICAID | 200545210A | 05 | OK | MEDICAID |