Provider Demographics
NPI:1235645730
Name:KECK, JULIE NADINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:NADINE
Last Name:KECK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:22362 GILBERTO STE 205
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-2153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22362 GILBERTO STE 205
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2153
Practice Address - Country:US
Practice Address - Phone:949-229-1138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14768103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist