Provider Demographics
NPI:1629611512
Name:KEITH, ANDREW J (MPA, MED, LPCC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:KEITH
Suffix:
Gender:M
Credentials:MPA, MED, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:419-695-8010
Mailing Address - Fax:419-695-0004
Practice Address - Street 1:149 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-6155
Practice Address - Country:US
Practice Address - Phone:606-679-6995
Practice Address - Fax:606-451-9465
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY280398101YP2500X, 101YM0800X
KY265747101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty