Basic Information
| Provider Information | |||||||||
| NPI: | 1164758918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEITZ | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-R | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3350 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142141316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168354011 | ||||||||
| FaxNumber: | 7168350253 | ||||||||
| Practice Location | |||||||||
| Address1: | 3350 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142141316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168354011 | ||||||||
| FaxNumber: | 7168350253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2009 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 080117-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.