1336256353 NPI number — DR. ELIZABETH TANNAHILL GLEN KEYMER PSYD

Table of content: DR. ELIZABETH TANNAHILL GLEN KEYMER PSYD (NPI 1336256353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336256353 NPI number — DR. ELIZABETH TANNAHILL GLEN KEYMER PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLEN KEYMER
Provider First Name:
ELIZABETH
Provider Middle Name:
TANNAHILL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KEYMER
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
TANNAHILL GLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSYD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1336256353
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 748519
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-8519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-376-3800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 PALM AVE STE 4A017
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207-8432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-376-3800
Provider Business Practice Location Address Fax Number:
904-390-7395
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  PY6757 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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