Healthcare Provider Details

I. General information

NPI: 1629274360
Provider Name (Legal Business Name): JOHN KEHOE L.I.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6950 E WILLIAMS FIELD RD
MESA AZ
85212-6033
US

IV. Provider business mailing address

6950 E WILLIAMS FIELD RD
MESA AZ
85212-6033
US

V. Phone/Fax

Practice location:
  • Phone: 602-222-2793
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06116
License Number StateNM

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: