Provider Demographics
NPI:1952815565
Name:KEITH WOYTHALER PSYCHOLOGIST, P.C.
Entity Type:Organization
Organization Name:KEITH WOYTHALER PSYCHOLOGIST, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:WOYTHALER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-851-5381
Mailing Address - Street 1:112 N FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4304
Mailing Address - Country:US
Mailing Address - Phone:516-851-5381
Mailing Address - Fax:
Practice Address - Street 1:100 N VILLAGE AVE STE 11
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3712
Practice Address - Country:US
Practice Address - Phone:516-851-5381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-20
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty