Provider Demographics
NPI:1669774543
Name:WEIGOLD, KEITH WARREN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:WARREN
Last Name:WEIGOLD
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 OASIS RD
Mailing Address - Street 2:
Mailing Address - City:BULLS GAP
Mailing Address - State:TN
Mailing Address - Zip Code:37711-2045
Mailing Address - Country:US
Mailing Address - Phone:423-438-8641
Mailing Address - Fax:
Practice Address - Street 1:100 NETHERLAND LN
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7245
Practice Address - Country:US
Practice Address - Phone:423-438-8641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-24
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13461235Z00000X
TN4200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1669774543Medicaid