MEDICARE: ANISSA NICOLE KEYES MA, LMFT, LICSW

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	106H00000X	Marriage & Family Therapist	2538	MN
2	1041C0700X	Clinical Social Worker	23288	MN

General Provider Information

NPI Number	:	1154686590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANISSA NICOLE KEYES MA, LMFT, LICSW

Provider Business Mailing Address
First Line	:	3300 COUNTY ROAD 10
Second Line	:	STE 204B
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55429-3072
Country	:	US
Telephone Number	:	763-447-5573
Fax Number	:	763-273-8892

Provider Business Practice Location Address
First Line	:	1437 MARSHALL AVE # 204
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-6350
Country	:	US
Telephone Number	:	612-284-8115
Fax Number	:	763-273-8892

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

Provider Enumeration Date	:	07/11/2012
Last Update Date	:	05/08/2018

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