Provider Demographics
NPI:1265022321
Name:KEEFER, TABATHA (PPC)
Entity Type:Individual
Prefix:
First Name:TABATHA
Middle Name:
Last Name:KEEFER
Suffix:
Gender:F
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4397 MCKENNA RD
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-8452
Mailing Address - Country:US
Mailing Address - Phone:307-575-1326
Mailing Address - Fax:
Practice Address - Street 1:1757 W C ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240-3215
Practice Address - Country:US
Practice Address - Phone:307-338-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1225101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty