Provider Demographics
NPI:1639888027
Name:KEITH, ETHAN M
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:M
Last Name:KEITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 ROYAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-2040
Mailing Address - Country:US
Mailing Address - Phone:616-826-7218
Mailing Address - Fax:
Practice Address - Street 1:201 ROYAL PARK DR
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-2040
Practice Address - Country:US
Practice Address - Phone:616-826-7218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician