Healthcare Provider Details

I. General information

NPI: 1295039329
Provider Name (Legal Business Name): KRISTY KECK L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

683 OLD MILL RD
MILLERSVILLE MD
21108-1326
US

IV. Provider business mailing address

683 OLD MILL RD
MILLERSVILLE MD
21108-1326
US

V. Phone/Fax

Practice location:
  • Phone: 410-530-3089
  • Fax:
Mailing address:
  • Phone: 410-530-3089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberM00845
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: