Healthcare Provider Details

I. General information

NPI: 1235645730
Provider Name (Legal Business Name): JULIE NADINE KECK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULIE OLSON PHD

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22362 GILBERTO STE 205
RANCHO SANTA MARGARITA CA
92688-2153
US

IV. Provider business mailing address

22362 GILBERTO STE 205
RANCHO SANTA MARGARITA CA
92688-2153
US

V. Phone/Fax

Practice location:
  • Phone: 949-229-1138
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY14768
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: