MEDICARE: KEITH JOHN MCNEAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	60773522	WA
2	104100000X	Social Worker	60773522	WA

General Provider Information

NPI Number	:	1013484781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH JOHN MCNEAL

Provider Business Mailing Address
First Line	:	9815 79TH ST SW
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98498-3207
Country	:	US
Telephone Number	:	253-777-5709
Fax Number	:

Provider Business Practice Location Address
First Line	:	5900 100TH ST SW STE 17B
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-2749
Country	:	US
Telephone Number	:	253-431-9739
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2018
Last Update Date	:	10/30/2018

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