Healthcare Provider Details

I. General information

NPI: 1285783498
Provider Name (Legal Business Name): MR. KEITH W BOYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1087 ALICE AVE
MEMPHIS TN
38106-6543
US

IV. Provider business mailing address

1116 CHARTER OAK DR
MEMPHIS TN
38109-4906
US

V. Phone/Fax

Practice location:
  • Phone: 901-259-1920
  • Fax: 901-259-1922
Mailing address:
  • Phone: 901-859-0036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: