Provider Demographics
NPI: | 1336256353 |
---|---|
Name: | GLEN KEYMER, ELIZABETH TANNAHILL (PSYD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | ELIZABETH |
Middle Name: | TANNAHILL |
Last Name: | GLEN KEYMER |
Suffix: | |
Gender: | F |
Credentials: | PSYD |
Other - Prefix: | |
Other - First Name: | ELIZABETH |
Other - Middle Name: | TANNAHILL GLEN |
Other - Last Name: | KEYMER |
Other - Suffix: | |
Other - Last Name Type: | Professional Name |
Other - Credentials: | PSYD |
Mailing Address - Street 1: | PO BOX 748519 |
Mailing Address - Street 2: | |
Mailing Address - City: | ATLANTA |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30374-8519 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 904-376-3800 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1301 PALM AVE STE 4A017 |
Practice Address - Street 2: | |
Practice Address - City: | JACKSONVILLE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32207-8432 |
Practice Address - Country: | US |
Practice Address - Phone: | 904-376-3800 |
Practice Address - Fax: | 904-390-7395 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-08-24 |
Last Update Date: | 2022-09-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | PY6757 | 103G00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103G00000X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 211997800 | Medicaid | |
FL | 666191158A | Medicaid | |
FL | U1065Y | Medicare PIN | |
FL | U1065Z | Medicare PIN |