Healthcare Provider Details

I. General information

NPI: 1255497376
Provider Name (Legal Business Name): SHANNETTE KEELER LCSW, PC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4184 W 1975 N
PLAIN CITY UT
84404-9716
US

IV. Provider business mailing address

4184 W 1975 N
PLAIN CITY UT
84404-9716
US

V. Phone/Fax

Practice location:
  • Phone: 801-732-1102
  • Fax: 801-732-1107
Mailing address:
  • Phone: 801-732-1102
  • Fax: 801-732-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number135206-3501
License Number StateUT

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: