Provider Demographics
NPI:1407973324
Name:KEATHLEY, ELIZABETH ALLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ALLEN
Last Name:KEATHLEY
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:PO BOX 813
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-0813
Mailing Address - Country:US
Mailing Address - Phone:802-388-3090
Mailing Address - Fax:
Practice Address - Street 1:64 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1426
Practice Address - Country:US
Practice Address - Phone:802-388-3090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT819103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010022Medicaid