Provider Demographics
NPI:1477646768
Name:HARRIS, KEITH D (PT, CMTPT, DAC)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:D
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PT, CMTPT, DAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2433 AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-3003
Mailing Address - Country:US
Mailing Address - Phone:757-334-9393
Mailing Address - Fax:
Practice Address - Street 1:2433 AUSTIN AVE STE B
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32738-3003
Practice Address - Country:US
Practice Address - Phone:757-334-9393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004493225100000X
FLPT38696225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA324581OtherANTHEM
VA650000463, C07072Medicare ID - Type Unspecified