Provider Demographics
NPI:1407902992
Name:KEYLOR, RHETA GRENOBLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:RHETA
Middle Name:GRENOBLE
Last Name:KEYLOR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 WOODWARD ST
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-2010
Mailing Address - Country:US
Mailing Address - Phone:617-630-9478
Mailing Address - Fax:
Practice Address - Street 1:289 WOODWARD ST
Practice Address - Street 2:
Practice Address - City:WABAN
Practice Address - State:MA
Practice Address - Zip Code:02468-2010
Practice Address - Country:US
Practice Address - Phone:617-630-9478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2633103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAKEWO2728Medicare UPIN