Provider Demographics
NPI:1861644197
Name:KEIL, MICHELLE L
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:KEIL
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 1:3158 E SIERRA MADRE AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-9455
Mailing Address - Country:US
Mailing Address - Phone:520-663-1242
Mailing Address - Fax:602-455-4624
Practice Address - Street 1:3158 E SIERRA MADRE AVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-9455
Practice Address - Country:US
Practice Address - Phone:602-663-1242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-17
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1558385HR2055X
253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child