Healthcare Provider Details

I. General information

NPI: 1447154364
Provider Name (Legal Business Name): KEYSIDE THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 PAYTON FALLS DR
AUSTIN TX
78754-5814
US

IV. Provider business mailing address

5900 BALCONES DR STE 100
AUSTIN TX
78731-4298
US

V. Phone/Fax

Practice location:
  • Phone: 301-820-2229
  • Fax:
Mailing address:
  • Phone: 301-820-2229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. THOMAS DYER STEPHAN JR.
Title or Position: OWNER
Credential: MED
Phone: 301-820-2229