Provider Demographics
NPI:1346045689
Name:KEITH, ASHLEY SUZETTE
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:SUZETTE
Last Name:KEITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 N BROAD ST APT 3
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-5567
Mailing Address - Country:US
Mailing Address - Phone:937-986-8904
Mailing Address - Fax:
Practice Address - Street 1:1428 N BROAD ST APT 3
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5567
Practice Address - Country:US
Practice Address - Phone:937-986-8904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH191589101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)