Provider Demographics
NPI:1003852005
Name:KEIDAN, CAROL (MA LLP)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:
Last Name:KEIDAN
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-1834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43996 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5028
Practice Address - Country:US
Practice Address - Phone:248-338-2988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005602103T00000X
MI4101005340103TF0000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0007336430OtherAETNA
MA181269OtherCOMPSYCH
MI028363OtherVAL OPT/MCARE/BCN
MI0911419OtherBLUE CHOICE/MAGELLAN/V.O
MI0913419OtherBC MESSA
MI5266701OtherAETNA
MI7509104190OtherBCBS
MI130958OtherCARE CHOICES