Provider Demographics
NPI:1487063244
Name:MARCANTEL, KEITH BERNARD (MA, MS, NCSP)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:BERNARD
Last Name:MARCANTEL
Suffix:
Gender:M
Credentials:MA, MS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 N BALDWIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-1374
Mailing Address - Country:US
Mailing Address - Phone:719-330-5753
Mailing Address - Fax:
Practice Address - Street 1:2802 N NEVADA AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6201
Practice Address - Country:US
Practice Address - Phone:719-471-4329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1376967885251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1376967885OtherSMART SCHOOLS PARTNERS NPI NUMBER
CO251C00000XOtherSMART SCHOOLS PARTNERS TYPE OF BUSINESS