Provider Demographics
NPI:1326541582
Name:VICTOR, KEELAN
Entity Type:Individual
Prefix:
First Name:KEELAN
Middle Name:
Last Name:VICTOR
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 1:590 LOWER LANDING RD APT 13B
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-4215
Mailing Address - Country:US
Mailing Address - Phone:856-542-8929
Mailing Address - Fax:
Practice Address - Street 1:210 S BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:BLACKWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08012-2955
Practice Address - Country:US
Practice Address - Phone:856-542-8929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health