Healthcare Provider Details

I. General information

NPI: 1629869912
Provider Name (Legal Business Name): KATHLEEN KECK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2025
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 GRANT ST
NEWARK OH
43055-3939
US

IV. Provider business mailing address

1801 WATERMARK DR
COLUMBUS OH
43215-7088
US

V. Phone/Fax

Practice location:
  • Phone: 740-349-7511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC.0007945
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: