=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184735185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEITH JON VAN LEUVEN LMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 4TH ST W
-----------------------------------------------------
City | PALMETTO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34221-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-722-7508
-----------------------------------------------------
Fax | 941-729-0380
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1020 4TH ST W
-----------------------------------------------------
City | PALMETTO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34221-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-722-7508
-----------------------------------------------------
Fax | 941-729-0380
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH3954
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------