Provider Demographics
NPI:1114541521
Name:KEITH, MISTY R (MFTA)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:R
Last Name:KEITH
Suffix:
Gender:F
Credentials:MFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12700 TOWNEPARK WAY STE 337
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2556
Mailing Address - Country:US
Mailing Address - Phone:502-203-5901
Mailing Address - Fax:
Practice Address - Street 1:12700 TOWNEPARK WAY STE 337
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-2556
Practice Address - Country:US
Practice Address - Phone:502-203-5901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY263894101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor