Provider Demographics
NPI:1295006013
Name:HALE, KEITHLEY ELISE
Entity Type:Individual
Prefix:
First Name:KEITHLEY
Middle Name:ELISE
Last Name:HALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEITHLEY
Other - Middle Name:ELISE
Other - Last Name:HALE-AGLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:23021 LAUREL GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4027
Mailing Address - Country:US
Mailing Address - Phone:949-632-8731
Mailing Address - Fax:
Practice Address - Street 1:1618 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-3614
Practice Address - Country:US
Practice Address - Phone:714-558-6009
Practice Address - Fax:714-558-6120
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator