Healthcare Provider Details

I. General information

NPI: 1134933427
Provider Name (Legal Business Name): KEATON HETTVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 E 24TH ST
MINNEAPOLIS MN
55404-3862
US

IV. Provider business mailing address

740 E 24TH ST
MINNEAPOLIS MN
55404-3862
US

V. Phone/Fax

Practice location:
  • Phone: 612-373-3366
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number27833
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: