Basic Information
| Provider Information | |||||||||
| NPI: | 1821584020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEITH | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSWA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARTLEY | ||||||||
| OtherFirstName: | TYLER | ||||||||
| OtherMiddleName: | JOSEPH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 615 SHIPYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284126431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102025709 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 615 SHIPYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284126431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102025709 | ||||||||
| FaxNumber: | 9102029966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2018 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | PO12606 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.