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General NPI Number Information
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NPI Number | 1831365154
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Entity Type | Organization
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Legal Business Name | KEYSTONE BEHAVIORAL PEDIATRICS, LLC
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Dates
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Enumeration Date | 05/06/2008
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Last Update Date | 05/12/2020
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Provider Practice Location Address
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Address Line | 172 CANAL BLVD
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-3606
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Country | US
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Telephone | 904-373-0748
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Fax | 904-671-7377
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Provider Business Mailing Address
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Address Line | 172 CANAL BLVD
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-3606
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Country | US
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Telephone | 904-373-0748
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Fax | 904-671-7377
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | KATHERINE FALWELL
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Credential | PH. D.
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Telephone | 904-373-0748
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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