Provider Demographics
NPI:1184073868
Name:KEYSTONE BEHAVIORAL HEALTH PLLC
Entity type:Organization
Organization Name:KEYSTONE BEHAVIORAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:734-646-5327
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:517-676-9788
Mailing Address - Fax:
Practice Address - Street 1:28175 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2903
Practice Address - Country:US
Practice Address - Phone:734-646-5327
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010826311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty