Healthcare Provider Details

I. General information

NPI: 1609608447
Provider Name (Legal Business Name): EMILY ELIZABETH KECK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 STATE AVE
FARIBAULT MN
55021-6339
US

IV. Provider business mailing address

5372 SW 82ND AVE
OWATONNA MN
55060-5021
US

V. Phone/Fax

Practice location:
  • Phone: 507-334-6451
  • Fax:
Mailing address:
  • Phone: 507-676-5368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226000000X
TaxonomyRecreational Therapist Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: