Healthcare Provider Details

I. General information

NPI: 1205359023
Provider Name (Legal Business Name): MISS SHELLY ROSE KEENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4394 30TH ST
SAN DIEGO CA
92104-1314
US

IV. Provider business mailing address

5623 SAPPHIRE LOOP
ANCHORAGE AK
99504-6001
US

V. Phone/Fax

Practice location:
  • Phone: 619-281-8313
  • Fax:
Mailing address:
  • Phone: 619-712-7012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number150415
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number150415
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: