Provider Demographics
NPI:1518012681
Name:KEITZ, TIFFANY A (SLP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:A
Last Name:KEITZ
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 E RANDOLPH AVE STE AND113
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-4670
Mailing Address - Country:US
Mailing Address - Phone:580-231-8081
Mailing Address - Fax:580-234-2615
Practice Address - Street 1:2615 E RANDOLPH AVE STE AND113
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-4670
Practice Address - Country:US
Practice Address - Phone:580-231-8081
Practice Address - Fax:405-254-5531
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3182235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200125650BMedicaid