Provider Demographics
NPI:1851701809
Name:IZZARD, KEISHAY (ED)
Entity Type:Individual
Prefix:
First Name:KEISHAY
Middle Name:
Last Name:IZZARD
Suffix:
Gender:F
Credentials:ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12955 WILLOW PLACE DR W
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-5651
Mailing Address - Country:US
Mailing Address - Phone:209-354-6234
Mailing Address - Fax:
Practice Address - Street 1:12955 WILLOW PLACE DR W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-5651
Practice Address - Country:US
Practice Address - Phone:209-354-6234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5682948106H00000X
103K00000X, 221700000X, 225600000X, 222Q00000X, 225700000X, 225A00000X, 101YM0800X, 385HR2055X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No347C00000XTransportation ServicesPrivate Vehicle