Provider Demographics
NPI:1508937814
Name:KEELY, PETER W (MA, DMIN)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:W
Last Name:KEELY
Suffix:
Gender:M
Credentials:MA, DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 MARKET STREET
Mailing Address - Street 2:SUITE 165 A
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701
Mailing Address - Country:US
Mailing Address - Phone:570-322-3226
Mailing Address - Fax:570-322-7742
Practice Address - Street 1:460 MARKET STREET
Practice Address - Street 2:SUITE 165 A
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701
Practice Address - Country:US
Practice Address - Phone:570-322-3226
Practice Address - Fax:570-322-7742
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004934L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA033915Medicare ID - Type UnspecifiedPSY