Provider Demographics
NPI:1821584020
Name:KEITH, TYLER JOSEPH (LCSWA)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JOSEPH
Last Name:KEITH
Suffix:
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:TYLER
Other - Middle Name:JOSEPH
Other - Last Name:HARTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:615 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6431
Mailing Address - Country:US
Mailing Address - Phone:910-202-5709
Mailing Address - Fax:
Practice Address - Street 1:615 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-6431
Practice Address - Country:US
Practice Address - Phone:910-202-5709
Practice Address - Fax:910-202-9966
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPO126061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical