Healthcare Provider Details

I. General information

NPI: 1649507658
Provider Name (Legal Business Name): STEPHANIE ANN KEANE PHD., NCC, LAT, LPC,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 SHERIDAN AVE
CODY WY
82414-3409
US

IV. Provider business mailing address

706 LONGMONT ST
GILLETTE WY
82716-2927
US

V. Phone/Fax

Practice location:
  • Phone: 307-578-2486
  • Fax: 307-578-2247
Mailing address:
  • Phone: 307-686-0669
  • Fax: 307-686-2121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number206
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number728
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: