Provider Demographics
NPI:1578747978
Name:KELTGEN, JOAN E (EDS)
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:E
Last Name:KELTGEN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1736 PIERSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-8035
Mailing Address - Country:US
Mailing Address - Phone:954-895-4644
Mailing Address - Fax:
Practice Address - Street 1:1736 PIERSIDE CIR
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-8035
Practice Address - Country:US
Practice Address - Phone:954-895-4644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS 1044174400000X
222Q00000X
FLSS1044103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No174400000XOther Service ProvidersSpecialist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003401500Medicaid