Provider Demographics
NPI:1477598936
Name:KEELIN, LORETTA BUSBY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LORETTA
Middle Name:BUSBY
Last Name:KEELIN
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 1:7800 W IH 10 STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-4776
Mailing Address - Country:US
Mailing Address - Phone:910-938-9338
Mailing Address - Fax:910-989-0377
Practice Address - Street 1:824 GUM BRANCH RD
Practice Address - Street 2:SUITE O
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-6269
Practice Address - Country:US
Practice Address - Phone:910-938-9338
Practice Address - Fax:910-989-0377
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0030271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2879718Medicare ID - Type Unspecified