MEDICARE: MRS. KELLY E O'KEEFE LCSW

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	149.018408	IL

General Provider Information

NPI Number	:	1538606058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY E O'KEEFE LCSW

Provider Business Mailing Address
First Line	:	1118 LARKSPUR CT
Second Line	:
City	:	PINGREE GROVE
State	:	IL
Zip	:	60140-9147
Country	:	US
Telephone Number	:	847-791-5094
Fax Number	:

Provider Business Practice Location Address
First Line	:	1118 LARKSPUR CT
Second Line	:
City	:	PINGREE GROVE
State	:	IL
Zip	:	60140-9147
Country	:	US
Telephone Number	:	847-791-5094
Fax Number	:

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

Provider Enumeration Date	:	01/22/2017
Last Update Date	:	01/22/2017

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