Healthcare Provider Details

I. General information

NPI: 1902452634
Provider Name (Legal Business Name): EVA KEATLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 08/29/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

6201 GREENLEIGH AVE FL 2
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-614-4030
  • Fax:
Mailing address:
  • Phone: 410-933-2704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number06439
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number06439
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: