Provider Demographics
NPI:1144233008
Name:KEITH, ANGELA LYNN (PHD, LPC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LYNN
Last Name:KEITH
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 W UNIVERSITY AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-773-7774
Mailing Address - Fax:928-774-1148
Practice Address - Street 1:1016 W UNIVERSITY AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-773-7774
Practice Address - Fax:928-774-1148
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-11038101YP2500X
AZ4035103TC1900X
AZ11038101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional