Provider Demographics
NPI:1457964843
Name:KEITH, MATELAND LESTERY III (PMHNP-ABC)
Entity Type:Individual
Prefix:MR
First Name:MATELAND
Middle Name:LESTERY
Last Name:KEITH
Suffix:III
Gender:M
Credentials:PMHNP-ABC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 COMMERCIAL CT STE B
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-1656
Mailing Address - Country:US
Mailing Address - Phone:941-244-4377
Mailing Address - Fax:941-445-4186
Practice Address - Street 1:421 COMMERCIAL CT STE B
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-1656
Practice Address - Country:US
Practice Address - Phone:941-244-4377
Practice Address - Fax:941-445-4186
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28243714A163WP0809X, 163WA0400X, 163WP0807X, 163WP0808X
FL11013737363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health