Provider Demographics
NPI:1366504292
Name:KEITH, SHIRLEY MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:MARIE
Last Name:KEITH
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 1:1925 N ADOLINE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-5121
Mailing Address - Country:US
Mailing Address - Phone:559-441-1464
Mailing Address - Fax:
Practice Address - Street 1:2171 N. FINE ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721
Practice Address - Country:US
Practice Address - Phone:559-455-2040
Practice Address - Fax:559-455-2041
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 153841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02240Medicare UPIN