Provider Demographics
NPI:1497374136
Name:ELDRIDGE, KEENAN
Entity Type:Individual
Prefix:
First Name:KEENAN
Middle Name:
Last Name:ELDRIDGE
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 1:8152 WASHINGTON BLVD APT 504
Mailing Address - Street 2:
Mailing Address - City:JESSUP
Mailing Address - State:MD
Mailing Address - Zip Code:20794-9572
Mailing Address - Country:US
Mailing Address - Phone:443-955-2973
Mailing Address - Fax:
Practice Address - Street 1:8950 MD-108
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045
Practice Address - Country:US
Practice Address - Phone:410-630-7140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician