Provider Demographics
NPI:1104015064
Name:KEITH, NANNETTE MARIE (MED, LBSW, LPC)
Entity Type:Individual
Prefix:MRS
First Name:NANNETTE
Middle Name:MARIE
Last Name:KEITH
Suffix:
Gender:F
Credentials:MED, LBSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 112
Mailing Address - Street 2:
Mailing Address - City:OLDEN
Mailing Address - State:TX
Mailing Address - Zip Code:76466-0112
Mailing Address - Country:US
Mailing Address - Phone:254-653-2340
Mailing Address - Fax:325-646-8559
Practice Address - Street 1:529 FM 3363
Practice Address - Street 2:
Practice Address - City:OLDEN
Practice Address - State:TX
Practice Address - Zip Code:76466
Practice Address - Country:US
Practice Address - Phone:254-653-2340
Practice Address - Fax:325-646-8559
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19546101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional