Provider Demographics
NPI:1093816522
Name:KEENAN, KIMBERLY ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:KEENAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 W GREENBRIAR DRIVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-691-0525
Mailing Address - Fax:
Practice Address - Street 1:914 W GLEN AVENUE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-693-2749
Practice Address - Fax:309-693-3894
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490073911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207975Medicare ID - Type Unspecified