MEDICARE: MR. TUCKER KEATLEY LMSW-CLINICAL

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	104100000X	Social Worker	14677	LA
2	1041C0700X	Clinical Social Worker	14677	LA
3	1041C0700X	Clinical Social Worker	6801108948	MI

General Provider Information

NPI Number	:	1821592296
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TUCKER KEATLEY LMSW-CLINICAL

Provider Business Mailing Address
First Line	:	2798 ROSELAND AVE
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48823-4752
Country	:	US
Telephone Number	:	734-415-4845
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 W GREENLAWN AVE STE 305
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48910-2889
Country	:	US
Telephone Number	:	517-346-8318
Fax Number	:

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

Provider Enumeration Date	:	03/21/2018
Last Update Date	:	08/28/2024

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