Healthcare Provider Details

I. General information

NPI: 1144233008
Provider Name (Legal Business Name): ANGELA LYNN KEITH PHD, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 02/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 W UNIVERSITY AVE SUITE 202
FLAGSTAFF AZ
86001
US

IV. Provider business mailing address

1016 W UNIVERSITY AVE SUITE 202
FLAGSTAFF AZ
86001
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-7774
  • Fax: 928-774-1148
Mailing address:
  • Phone: 928-773-7774
  • Fax: 928-774-1148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-11038
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4035
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11038
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: