Basic Information
Provider Information
NPI: 1861644197
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KEIL
FirstName: MICHELLE
MiddleName: L.
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3158 E SIERRA MADRE AVE
Address2:  
City: GILBERT
State: AZ
PostalCode: 852969455
CountryCode: US
TelephoneNumber: 5206631242
FaxNumber: 6024554624
Practice Location
Address1: 3158 E SIERRA MADRE AVE
Address2:  
City: GILBERT
State: AZ
PostalCode: 852969455
CountryCode: US
TelephoneNumber: 6026631242
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/17/2008
LastUpdateDate: 03/11/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 03/11/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
385HR2055X1558AZN Respite Care FacilityRespite CareRespite Care, Mental Illness, Child
253J00000X  Y AgenciesFoster Care Agency 

No ID Information.


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