Provider Demographics
NPI:1316017817
Name:KEITA, AISSATA II
Entity Type:Individual
Prefix:
First Name:AISSATA
Middle Name:
Last Name:KEITA
Suffix:II
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 1:5818 E ROSEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-1533
Mailing Address - Country:US
Mailing Address - Phone:520-514-2121
Mailing Address - Fax:
Practice Address - Street 1:5818 E ROSEWOOD ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1533
Practice Address - Country:US
Practice Address - Phone:520-514-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2647320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ095265Medicaid