1548348659 NPI number — MRS. SUSAN M KEOGH LCPC

Table of content: MRS. SUSAN M KEOGH LCPC (NPI 1548348659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548348659 NPI number — MRS. SUSAN M KEOGH LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEOGH
Provider First Name:
SUSAN
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548348659
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
405 KAYS DRIVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
NORMAL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-532-3390
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 KAYS DRIVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
NORMAL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-862-0064
Provider Business Practice Location Address Fax Number:
309-862-1542
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  180001161 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 101694 . This is a "HEALTH ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5723204 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 202808 . This is a "MHN" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com