Provider Demographics
NPI:1174808695
Name:KEITH, LAENE M
Entity type:Individual
Prefix:
First Name:LAENE
Middle Name:M
Last Name:KEITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5208 WEXFORD DR
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5208 WEXFORD DR
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32955-6704
Practice Address - Country:US
Practice Address - Phone:321-271-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-16
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6260235Z00000X
FLL-22092174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist