Healthcare Provider Details

I. General information

NPI: 1508452913
Provider Name (Legal Business Name): REBECCA LYNN KECK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2020
Last Update Date: 02/18/2023
Certification Date: 02/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 S KIRKMAN RD STE 229
ORLANDO FL
32819-7940
US

IV. Provider business mailing address

5401 S KIRKMAN RD STE 229
ORLANDO FL
32819-7940
US

V. Phone/Fax

Practice location:
  • Phone: 407-917-0874
  • Fax:
Mailing address:
  • Phone: 407-917-0874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH20165
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH21563
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: