MEDICARE: MR. GEREMY F. KEETON M.MFT, LMFT

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	101YP1600X	Pastoral Counselor		TX
2	106H00000X	Marriage & Family Therapist	724	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	27-4224058	OTHER	CO	GK COUNSELING & THERAPEUTIC SERVICES, LLC (REGISTERED IN COLORADO)

General Provider Information

NPI Number	:	1831479369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GEREMY F. KEETON M.MFT, LMFT

Provider Business Mailing Address
First Line	:	2050 BRAMBLWOOD LN
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-1588
Country	:	US
Telephone Number	:	719-310-2995
Fax Number	:

Provider Business Practice Location Address
First Line	:	2050 BRAMBLWOOD LN
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-1588
Country	:	US
Telephone Number	:	719-310-2995
Fax Number	:

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

Provider Enumeration Date	:	08/29/2011
Last Update Date	:	08/29/2011

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