MEDICARE: KIMBERLY LOUISE KEON

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	87900033A	IN
2	101YM0800X	Mental Health Counselor	88001118A	IN

General Provider Information

NPI Number	:	1134865322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY LOUISE KEON

Provider Business Mailing Address
First Line	:	7035 KNICKERBOCKER PKWY
Second Line	:
City	:	HAMMOND
State	:	IN
Zip	:	46323-2028
Country	:	US
Telephone Number	:	773-655-2924
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 INDIAN BOUNDARY RD
Second Line	:
City	:	CHESTERTON
State	:	IN
Zip	:	46304-1511
Country	:	US
Telephone Number	:	219-308-1570
Fax Number	:

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

Provider Enumeration Date	:	05/10/2022
Last Update Date	:	05/10/2022

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