1568433811 NPI number — MS. SUSAN KEENE L.C.S.W.

Table of content: MS. SUSAN KEENE L.C.S.W. (NPI 1568433811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568433811 NPI number — MS. SUSAN KEENE L.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEENE
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W.
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:
1568433811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 S 1300 E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84102-3206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-538-2057
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
443 S 600 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84102-2708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-538-2057
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2006

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: 1041C0700X , with the licence number:  3123283501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003117003 . This is a "RAILROAD 'CARE RCAR" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: Q07205 . This is a "ICAR MEDICARE ADVANTAGE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 740409 . This is a "U002 DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 942938348KE1 . This is a "U003 EDUCATRS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107011057101 . This is a "U006 INTRMT HEALTH CARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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