Provider Demographics
NPI:1366927022
Name:BARTLEY, KEEVA
Entity type:Individual
Prefix:
First Name:KEEVA
Middle Name:
Last Name:BARTLEY
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 1:2990 N PERRYVILLE RD UNIT 1100
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6827
Mailing Address - Country:US
Mailing Address - Phone:815-469-1500
Mailing Address - Fax:
Practice Address - Street 1:2990 N PERRYVILLE RD UNIT 1100
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6827
Practice Address - Country:US
Practice Address - Phone:815-469-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IL1-21-53979103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician