Provider Demographics
NPI:1184848327
Name:KEITHLY, LOIS JEAN (PHD)
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:JEAN
Last Name:KEITHLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-7831
Mailing Address - Country:US
Mailing Address - Phone:781-641-0457
Mailing Address - Fax:
Practice Address - Street 1:68 LEONARD ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-2522
Practice Address - Country:US
Practice Address - Phone:781-641-0457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3853103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAKE W03903Medicare ID - Type Unspecified