Provider Demographics
NPI:1578596359
Name:PRINCE, DAVID KEELTY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:KEELTY
Last Name:PRINCE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 WALNUT ST
Mailing Address - Street 2:SUITE 1404
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3419
Mailing Address - Country:US
Mailing Address - Phone:215-772-1031
Mailing Address - Fax:215-772-1032
Practice Address - Street 1:1518 WALNUT ST
Practice Address - Street 2:SUITE 1404
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3419
Practice Address - Country:US
Practice Address - Phone:215-772-1031
Practice Address - Fax:215-772-1032
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015449103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
075103Medicare ID - Type Unspecified