Provider Demographics
NPI:1871867945
Name:KEITHLEY, BLAKE (MS EDS)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:KEITHLEY
Suffix:
Gender:M
Credentials:MS EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 W FRANK ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:IN
Mailing Address - Zip Code:47446-1748
Mailing Address - Country:US
Mailing Address - Phone:812-583-5094
Mailing Address - Fax:
Practice Address - Street 1:2325 Q ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-4718
Practice Address - Country:US
Practice Address - Phone:812-279-4673
Practice Address - Fax:812-279-4672
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health