MEDICARE: SHANNETTE KEELER LCSW, PC.

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	135206-3501	UT

General Provider Information

NPI Number	:	1255497376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNETTE KEELER LCSW, PC.

Provider Business Mailing Address
First Line	:	4184 W 1975 N
Second Line	:
City	:	PLAIN CITY
State	:	UT
Zip	:	84404-9716
Country	:	US
Telephone Number	:	801-732-1102
Fax Number	:	801-732-1107

Provider Business Practice Location Address
First Line	:	4184 W 1975 N
Second Line	:
City	:	PLAIN CITY
State	:	UT
Zip	:	84404-9716
Country	:	US
Telephone Number	:	801-732-1102
Fax Number	:	801-732-1107

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

Provider Enumeration Date	:	01/01/2007
Last Update Date	:	07/08/2007

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