MEDICARE: TARA KEEGAN MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	44SC05500200	NY
2	104100000X	Social Worker	5439-S	NV
3	1041C0700X	Clinical Social Worker	INTERN-IC-569	NV

General Provider Information

NPI Number	:	1578890919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA KEEGAN MSW, LCSW

Provider Business Mailing Address
First Line	:	12 OAK TER
Second Line	:
City	:	SUFFERN
State	:	NY
Zip	:	10901-5907
Country	:	US
Telephone Number	:	914-450-5771
Fax Number	:

Provider Business Practice Location Address
First Line	:	4660 S EASTERN AVE
Second Line	:	#104A
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6137
Country	:	US
Telephone Number	:	702-451-7542
Fax Number	:	702-450-4239

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2009
Last Update Date	:	03/20/2012

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