Provider Demographics
NPI:1699528109
Name:BLUE, KEON IVORY
Entity type:Individual
Prefix:
First Name:KEON
Middle Name:IVORY
Last Name:BLUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1783 NW 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33311-4254
Mailing Address - Country:US
Mailing Address - Phone:954-899-7573
Mailing Address - Fax:
Practice Address - Street 1:7601 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-1657
Practice Address - Country:US
Practice Address - Phone:754-399-8507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24338698106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician