Provider Demographics
NPI:1255497376
Name:KEELER, SHANNETTE (LCSW, PC)
Entity Type:Individual
Prefix:
First Name:SHANNETTE
Middle Name:
Last Name:KEELER
Suffix:
Gender:F
Credentials:LCSW, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4184 W 1975 N
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84404-9716
Mailing Address - Country:US
Mailing Address - Phone:801-732-1102
Mailing Address - Fax:801-732-1107
Practice Address - Street 1:4184 W 1975 N
Practice Address - Street 2:
Practice Address - City:PLAIN CITY
Practice Address - State:UT
Practice Address - Zip Code:84404-9716
Practice Address - Country:US
Practice Address - Phone:801-732-1102
Practice Address - Fax:801-732-1107
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT135206-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical