Provider Demographics
NPI:1205199064
Name:MARVIN, KEELY
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:
Last Name:MARVIN
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:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:CENTRAL VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10917-0368
Mailing Address - Country:US
Mailing Address - Phone:845-928-2579
Mailing Address - Fax:845-928-2729
Practice Address - Street 1:66 WASHINGTON DR
Practice Address - Street 2:
Practice Address - City:HIGHLAND MILLS
Practice Address - State:NY
Practice Address - Zip Code:10930-3030
Practice Address - Country:US
Practice Address - Phone:845-928-2579
Practice Address - Fax:845-928-2729
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator