Provider Demographics
NPI:1093187635
Name:KECK, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:KECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13443 BISHOP STREET RD
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:NY
Mailing Address - Zip Code:13605-2171
Mailing Address - Country:US
Mailing Address - Phone:315-405-1839
Mailing Address - Fax:
Practice Address - Street 1:70 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ADAMS
Practice Address - State:NY
Practice Address - Zip Code:13605-3102
Practice Address - Country:US
Practice Address - Phone:315-405-1839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025893-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist