Basic Information
| Provider Information | |||||||||
| NPI: | 1477092930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELYEA | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 BUSH LAKE LN | ||||||||
| Address2: | |||||||||
| City: | KIMBALL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480741349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108413230 | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109844202 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2017 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.