Healthcare Provider Details

I. General information

NPI: 1336256353
Provider Name (Legal Business Name): ELIZABETH TANNAHILL GLEN KEYMER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH TANNAHILL GLEN KEYMER PSYD

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PALM AVE STE 4A017
JACKSONVILLE FL
32207-8432
US

IV. Provider business mailing address

PO BOX 748519
ATLANTA GA
30374-8519
US

V. Phone/Fax

Practice location:
  • Phone: 904-376-3800
  • Fax: 904-390-7395
Mailing address:
  • Phone: 904-376-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY6757
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY6757
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: