Provider Demographics
NPI:1750357869
Name:MIESSAU, KEITH WILLIAM (ATC, LAT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:WILLIAM
Last Name:MIESSAU
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 HUNTERS STAND RUN
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-5100
Mailing Address - Country:US
Mailing Address - Phone:407-619-0951
Mailing Address - Fax:
Practice Address - Street 1:655 LONGWOOD LAKE MARY RD
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3701
Practice Address - Country:US
Practice Address - Phone:407-320-9753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 19302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer