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
StateLicense IDTaxonomies
FLPY6757103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL211997800Medicaid
FL666191158AMedicaid
FLU1065YMedicare PIN
FLU1065ZMedicare PIN