Healthcare Provider Details

I. General information

NPI: 1346056207
Provider Name (Legal Business Name): KEITH JARED ANTHONY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 N CENTER ST
CORRY PA
16407-1626
US

IV. Provider business mailing address

523 E MAIN ST
SPARTANSBURG PA
16434-1009
US

V. Phone/Fax

Practice location:
  • Phone: 814-462-7869
  • Fax: 814-664-2552
Mailing address:
  • Phone: 814-964-1216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC000703
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: