Provider Demographics
NPI:1417428178
Name:KEENAN, MICHAEL (LSUDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KEENAN
Suffix:
Gender:M
Credentials:LSUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 S 1280 E
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-8553
Mailing Address - Country:US
Mailing Address - Phone:435-680-1459
Mailing Address - Fax:
Practice Address - Street 1:1223 S 1280 E
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-8553
Practice Address - Country:US
Practice Address - Phone:435-680-1459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5649814-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)