MEDICARE: CAROLYN THERESA KEEHN RBT

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	106S00000X	Behavior Technician	18-54302	IL

General Provider Information

NPI Number	:	1578053021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN THERESA KEEHN RBT

Provider Business Mailing Address
First Line	:	1361 CUNAT CT APT 1D
Second Line	:
City	:	LAKE IN THE HILLS
State	:	IL
Zip	:	60156-6123
Country	:	US
Telephone Number	:	224-623-4885
Fax Number	:

Provider Business Practice Location Address
First Line	:	1361 CUNAT CT APT 1D
Second Line	:
City	:	LAKE IN THE HILLS
State	:	IL
Zip	:	60156-6123
Country	:	US
Telephone Number	:	224-623-4885
Fax Number	:

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

Provider Enumeration Date	:	05/10/2018
Last Update Date	:	05/10/2018

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