Provider Demographics
NPI:1083360408
Name:KEYSTONE BEHAVIORAL PEDIATRICS, LLC
Entity Type:Organization
Organization Name:KEYSTONE BEHAVIORAL PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:DELANEY
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:904-373-0082
Mailing Address - Street 1:172 CANAL BLVD
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3606
Mailing Address - Country:US
Mailing Address - Phone:904-373-0082
Mailing Address - Fax:904-671-7377
Practice Address - Street 1:185 LANDRUM LN STE 100
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3824
Practice Address - Country:US
Practice Address - Phone:904-373-0082
Practice Address - Fax:904-671-7377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty