Provider Demographics
NPI:1588301857
Name:KEITH, MELINDA MARIE (CPSS)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:MARIE
Last Name:KEITH
Suffix:
Gender:F
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4114 W HIGHWAY 80
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3761
Mailing Address - Country:US
Mailing Address - Phone:606-872-8929
Mailing Address - Fax:
Practice Address - Street 1:80 HIGHWAY 2227
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-1562
Practice Address - Country:US
Practice Address - Phone:606-485-4003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1201032175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist