Provider Demographics
NPI:1164643581
Name:KEOUGH, JOHN ALLEN (MA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALLEN
Last Name:KEOUGH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 4 BOX 658
Mailing Address - Street 2:PO BOX 472
Mailing Address - City:BUTLER
Mailing Address - State:MO
Mailing Address - Zip Code:64730-9458
Mailing Address - Country:US
Mailing Address - Phone:660-679-4421
Mailing Address - Fax:660-679-4421
Practice Address - Street 1:RR 4 BOX 658
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:MO
Practice Address - Zip Code:64730-9458
Practice Address - Country:US
Practice Address - Phone:660-679-4421
Practice Address - Fax:660-679-4421
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01651103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0031336OtherDDS VENDOR NUMBER