Provider Demographics
NPI:1275630469
Name:KEELIN, PETER WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:WILLIAM
Last Name:KEELIN
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 1:6008 W BEACH DR
Mailing Address - Street 2:
Mailing Address - City:OAK ISLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28465-7929
Mailing Address - Country:US
Mailing Address - Phone:248-625-7320
Mailing Address - Fax:
Practice Address - Street 1:6300 SASHABAW RD
Practice Address - Street 2:SUITE D
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2269
Practice Address - Country:US
Practice Address - Phone:248-625-7320
Practice Address - Fax:248-625-7320
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002813103T00000X, 103TF0200X
MI6310002813103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR83783Medicare UPIN
MI0F34644Medicare ID - Type Unspecified