Provider Demographics
NPI:1700294071
Name:TIFFANY KEITZ SPEECH PATHOLOGY PLLC
Entity type:Organization
Organization Name:TIFFANY KEITZ SPEECH PATHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC SLP
Authorized Official - Phone:580-231-8081
Mailing Address - Street 1:2615 E RANDOLPH
Mailing Address - Street 2:STE 112
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-4670
Mailing Address - Country:US
Mailing Address - Phone:580-231-8081
Mailing Address - Fax:580-234-2615
Practice Address - Street 1:2615 E RANDOLPH
Practice Address - Street 2:STE 112
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-4670
Practice Address - Country:US
Practice Address - Phone:580-231-8081
Practice Address - Fax:580-234-2615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3182235Z00000X
261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200125650BMedicaid
OK200545210AMedicaid