Provider Demographics
NPI:1447642806
Name:KECK, ASHLEY NICOLE (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
Last Name:KECK
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 CLEARWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8190
Mailing Address - Country:US
Mailing Address - Phone:574-361-9008
Mailing Address - Fax:
Practice Address - Street 1:2811 CLEARWATER AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8190
Practice Address - Country:US
Practice Address - Phone:574-361-9008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0034252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer