Provider Demographics
NPI:1083277909
Name:KEY-GRIFFIN, KEIDRA L (DT)
Entity Type:Individual
Prefix:
First Name:KEIDRA
Middle Name:L
Last Name:KEY-GRIFFIN
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18357 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-2905
Mailing Address - Country:US
Mailing Address - Phone:708-248-0854
Mailing Address - Fax:708-474-3788
Practice Address - Street 1:18357 OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-2905
Practice Address - Country:US
Practice Address - Phone:708-248-0854
Practice Address - Fax:708-474-3788
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL316268440Medicaid