Provider Demographics
NPI:1275689515
Name:KEILMAN, PEGGY A (PHD)
Entity type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:A
Last Name:KEILMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 WALDEN RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-8379
Mailing Address - Country:US
Mailing Address - Phone:505-890-4239
Mailing Address - Fax:
Practice Address - Street 1:4216 BALLOON PARK RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5801
Practice Address - Country:US
Practice Address - Phone:505-344-5470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM300103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM206038OtherDEPT. ED,LEVEL 3A,TYPE906
NMS3174Medicaid