Healthcare Provider Details

I. General information

NPI: 1134865322
Provider Name (Legal Business Name): KIMBERLY LOUISE KEON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 45TH ST
MUNSTER IN
46321-2818
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-852-2513
  • Fax: 317-865-1479
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number88001118A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: