Provider Demographics
NPI:1609897024
Name:KEITH, COLLEEN M (MACCCA)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:M
Last Name:KEITH
Suffix:
Gender:F
Credentials:MACCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:560 W MITCHELL ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2275
Mailing Address - Country:US
Mailing Address - Phone:231-439-6844
Mailing Address - Fax:231-487-0728
Practice Address - Street 1:560 W MITCHELL ST
Practice Address - Street 2:SUITE 250
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2275
Practice Address - Country:US
Practice Address - Phone:231-439-6844
Practice Address - Fax:231-487-0728
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000006237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4337275Medicaid
MI4708524Medicaid
MI4337275Medicaid
MIS47927Medicare UPIN