Provider Demographics
NPI:1790801462
Name:KEITH, TRICIA (PTA)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 LAKEWOOD PKWY E
Mailing Address - Street 2:#3083
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3830 LAKEWOOD PKWY E
Practice Address - Street 2:#3083
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7385
Practice Address - Country:US
Practice Address - Phone:847-456-0938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant