MEDICARE: JUDITH KEATLEY MSW, 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	1041C0700X	Clinical Social Worker	DP00944512	WV

General Provider Information

NPI Number	:	1558883959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDITH KEATLEY MSW, LICSW

Provider Business Mailing Address
First Line	:	PO BOX 71
Second Line	:
City	:	BUNKER HILL
State	:	WV
Zip	:	25413-0071
Country	:	US
Telephone Number	:	304-620-5512
Fax Number	:

Provider Business Practice Location Address
First Line	:	239 CHIMNEY DR
Second Line	:
City	:	BUNKER HILL
State	:	WV
Zip	:	25413-3171
Country	:	US
Telephone Number	:	304-620-5512
Fax Number	:

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

Provider Enumeration Date	:	07/07/2017
Last Update Date	:	06/18/2023

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