Provider Demographics
NPI:1790180453
Name:KEEHLER, TIM RYAN (RSA)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:RYAN
Last Name:KEEHLER
Suffix:
Gender:M
Credentials:RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHANA
Mailing Address - State:IL
Mailing Address - Zip Code:61015-9732
Mailing Address - Country:US
Mailing Address - Phone:815-501-7366
Mailing Address - Fax:
Practice Address - Street 1:555 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-2310
Practice Address - Country:US
Practice Address - Phone:815-561-9003
Practice Address - Fax:815-562-6692
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness