Provider Demographics
NPI:1548415953
Name:WOYTHALER, KEITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:WOYTHALER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N VILLAGE AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3712
Mailing Address - Country:US
Mailing Address - Phone:516-690-9555
Mailing Address - Fax:
Practice Address - Street 1:100 N VILLAGE AVE STE 11
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570
Practice Address - Country:US
Practice Address - Phone:516-690-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-26
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017909103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical