MEDICARE: STEPHEN KEELEY M.S., LPC

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	101YP2500X	Professional Counselor	C2662	OR

General Provider Information

NPI Number	:	1649584509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN KEELEY M.S., LPC

Provider Business Mailing Address
First Line	:	2304 E BURNSIDE ST
Second Line	:	SUITE 202
City	:	PORTLAND
State	:	OR
Zip	:	97214-1677
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2304 E BURNSIDE ST
Second Line	:	SUITE 202
City	:	PORTLAND
State	:	OR
Zip	:	97214-1677
Country	:	US
Telephone Number	:	503-228-9229
Fax Number	:	503-228-9558

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

Provider Enumeration Date	:	08/03/2010
Last Update Date	:	01/02/2012

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