Healthcare Provider Details

I. General information

NPI: 1588390637
Provider Name (Legal Business Name): LISA M KECK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 MADISON RD
CINCINNATI OH
45206
US

IV. Provider business mailing address

1501 MADISON RD
CINCINNATI OH
45206
US

V. Phone/Fax

Practice location:
  • Phone: 513-354-5200
  • Fax: 513-354-7115
Mailing address:
  • Phone: 513-354-5200
  • Fax: 513-354-7115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0002772
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.180655
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: