Provider Demographics
NPI:1558449934
Name:EBLE, KEITH WALTER (PHD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:WALTER
Last Name:EBLE
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 1:2770 INDIAN RIVER BLVD
Mailing Address - Street 2:325
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4299
Mailing Address - Country:US
Mailing Address - Phone:772-778-2613
Mailing Address - Fax:
Practice Address - Street 1:2770 INDIAN RIVER BLVD
Practice Address - Street 2:325
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4299
Practice Address - Country:US
Practice Address - Phone:772-778-2613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 5825103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54396Medicare ID - Type UnspecifiedPARTICIPATING PSYCHOLOGIS