Provider Demographics
NPI:1710712310
Name:PARKER, KEONTAY DELMARR
Entity type:Individual
Prefix:
First Name:KEONTAY
Middle Name:DELMARR
Last Name:PARKER
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 1:2300 GUTHRIE AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3529
Mailing Address - Country:US
Mailing Address - Phone:248-619-6792
Mailing Address - Fax:
Practice Address - Street 1:32100 TELEGRAPH RD STE 205
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-2454
Practice Address - Country:US
Practice Address - Phone:248-712-4266
Practice Address - Fax:248-712-4381
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician