Provider Demographics
NPI:1427221381
Name:KEIGLEY, RANDALL W (MSW)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:W
Last Name:KEIGLEY
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 GERSHWIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5859
Mailing Address - Country:US
Mailing Address - Phone:920-391-4700
Mailing Address - Fax:920-391-4870
Practice Address - Street 1:3150 GERSHWIN DRIVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5859
Practice Address - Country:US
Practice Address - Phone:920-391-4700
Practice Address - Fax:920-391-4870
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39693600Medicaid