Provider Demographics
NPI:1851942478
Name:KEENON, PHYLLIS D
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:D
Last Name:KEENON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 PARSONS AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-2398
Mailing Address - Country:US
Mailing Address - Phone:614-705-1919
Mailing Address - Fax:614-705-1868
Practice Address - Street 1:895 PARSONS AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206-2398
Practice Address - Country:US
Practice Address - Phone:614-705-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH251S00000XMedicaid