Provider Demographics
NPI:1245362664
Name:KEITH, RALPH PAUL (PHD)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:PAUL
Last Name:KEITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 LITTLE LAKE DR APT 9
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-6212
Mailing Address - Country:US
Mailing Address - Phone:734-516-5470
Mailing Address - Fax:
Practice Address - Street 1:424 LITTLE LAKE DR APT 9
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-6212
Practice Address - Country:US
Practice Address - Phone:734-516-5470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301000703103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
042902OtherVALUE OPTIONS
OC81152OtherBCBS
OC81152OtherBCBS