Provider Demographics
NPI:1417643446
Name:SHATSOFF, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:SHATSOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2798 IMPERIAL POINT TER
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-5245
Mailing Address - Country:US
Mailing Address - Phone:201-913-9302
Mailing Address - Fax:
Practice Address - Street 1:2798 IMPERIAL POINT TER
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-5245
Practice Address - Country:US
Practice Address - Phone:201-913-9302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst