Provider Demographics
NPI:1568020451
Name:KEELER, MISTY C (LMT)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:C
Last Name:KEELER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:
Other - Last Name:SELLARS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:4061 IDEWILD LOOP UNIT 306
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-7094
Mailing Address - Country:US
Mailing Address - Phone:208-699-0931
Mailing Address - Fax:
Practice Address - Street 1:4061 IDEWILD LOOP UNIT 306
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-7094
Practice Address - Country:US
Practice Address - Phone:208-620-0931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-3758225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMAS-3758OtherLMT