Healthcare Provider Details

I. General information

NPI: 1629041181
Provider Name (Legal Business Name): MICHAEL MACCALMONT KEIL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1993 CATO AVE
STATE COLLEGE PA
16801-2754
US

IV. Provider business mailing address

1993 CATO AVE
STATE COLLEGE PA
16801-2754
US

V. Phone/Fax

Practice location:
  • Phone: 814-231-8820
  • Fax: 814-231-8857
Mailing address:
  • Phone: 814-231-8820
  • Fax: 814-231-8857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS015879
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: