Provider Demographics
NPI:1154686590
Name:KEYES, ANISSA NICOLE (MA, LMFT, LICSW)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:NICOLE
Last Name:KEYES
Suffix:
Gender:F
Credentials:MA, LMFT, LICSW
Other - Prefix:
Other - First Name:ANISSA
Other - Middle Name:KEYES
Other - Last Name:BEASLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LMFT, LICSW
Mailing Address - Street 1:3300 COUNTY ROAD 10
Mailing Address - Street 2:STE 204B
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3072
Mailing Address - Country:US
Mailing Address - Phone:763-447-5573
Mailing Address - Fax:763-273-8892
Practice Address - Street 1:1437 MARSHALL AVE # 204
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6350
Practice Address - Country:US
Practice Address - Phone:612-284-8115
Practice Address - Fax:763-273-8892
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2538106H00000X
MN232881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical