Provider Demographics
NPI:1407268873
Name:KEESE, MARYANN
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:KEESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-0951
Mailing Address - Country:US
Mailing Address - Phone:888-873-4221
Mailing Address - Fax:
Practice Address - Street 1:3131 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-0951
Practice Address - Country:US
Practice Address - Phone:888-873-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5811224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant