Provider Demographics
NPI:1801079959
Name:KEITHLY, PAIGE SUSANNA (PHD)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:SUSANNA
Last Name:KEITHLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8025 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-6864
Mailing Address - Country:US
Mailing Address - Phone:580-237-6847
Mailing Address - Fax:
Practice Address - Street 1:8025 N 30TH ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-6864
Practice Address - Country:US
Practice Address - Phone:580-237-6847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-12
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK325231H00000X
OK3009235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist