Provider Demographics
NPI:1225347206
Name:MATTHEWS, KEITH HOWARD (LIMITED LICENSE)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:HOWARD
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:LIMITED LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 CAPITAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-4834
Mailing Address - Country:US
Mailing Address - Phone:269-317-2772
Mailing Address - Fax:269-282-0006
Practice Address - Street 1:360 CAPITAL AVE NE
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-4834
Practice Address - Country:US
Practice Address - Phone:269-317-2772
Practice Address - Fax:269-282-0006
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011119101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health