MEDICARE: KRISTIN M KEELER, S.C

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	103TC0700X	Clinical Psychologist	071-006391	IL
2	103TC0700X	Clinical Psychologist	2277-057	WI

General Provider Information

NPI Number	:	1336412360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KRISTIN M KEELER, S.C

Provider Business Mailing Address
First Line	:	4217 GREEN BAY RD
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53144-4518
Country	:	US
Telephone Number	:	262-652-2365
Fax Number	:	262-652-2071

Provider Business Practice Location Address
First Line	:	4217 GREEN BAY RD
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53144-4518
Country	:	US
Telephone Number	:	262-652-2365
Fax Number	:	262-652-2071

Authorized Official
Title or Position	:	PSYCHOLOGIST/OWNER
Name	:	DR. KRISTIN MARIE KEELER
Credential	:	PSYD
Telephone Number	:	262-652-2365

Provider Enumeration Date	:	02/22/2012
Last Update Date	:	02/22/2012

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