Provider Demographics
NPI:1629085717
Name:MAGNUS, KEITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:MAGNUS
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 1:10293 N MERIDIAN ST
Mailing Address - Street 2:SUITE 375
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1123
Mailing Address - Country:US
Mailing Address - Phone:317-581-2288
Mailing Address - Fax:317-581-2295
Practice Address - Street 1:10293 N MERIDIAN ST
Practice Address - Street 2:SUITE 375
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1123
Practice Address - Country:US
Practice Address - Phone:317-581-2288
Practice Address - Fax:317-581-2295
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041351103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN227830BMedicare ID - Type UnspecifiedMEDICARE