Provider Demographics
NPI:1427731132
Name:KEITHLEY, REGAN
Entity type:Individual
Prefix:
First Name:REGAN
Middle Name:
Last Name:KEITHLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 E STATE HIGHWAY 114 STE 160
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5261
Mailing Address - Country:US
Mailing Address - Phone:949-401-3931
Mailing Address - Fax:888-403-6922
Practice Address - Street 1:950 E STATE HIGHWAY 114 STE 160
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5261
Practice Address - Country:US
Practice Address - Phone:949-401-3931
Practice Address - Fax:888-403-6922
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20-139895106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician