Provider Demographics
NPI:1972746980
Name:MUNNINGHAM, KEITH WILFRED
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:WILFRED
Last Name:MUNNINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 MAXWELL RD
Mailing Address - Street 2:
Mailing Address - City:MONSON
Mailing Address - State:MA
Mailing Address - Zip Code:01057-9437
Mailing Address - Country:US
Mailing Address - Phone:413-283-9926
Mailing Address - Fax:
Practice Address - Street 1:48 MAXWELL RD
Practice Address - Street 2:
Practice Address - City:MONSON
Practice Address - State:MA
Practice Address - Zip Code:01057-9437
Practice Address - Country:US
Practice Address - Phone:413-283-9926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1825224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant