Provider Demographics
NPI:1568433811
Name:KEENE, SUSAN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:KEENE
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 1:611 S 1300 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-3206
Mailing Address - Country:US
Mailing Address - Phone:801-538-2057
Mailing Address - Fax:
Practice Address - Street 1:443 S 600 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2708
Practice Address - Country:US
Practice Address - Phone:801-538-2057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT31232835011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT003117003OtherRAILROAD 'CARE RCAR
UTQ07205OtherICAR MEDICARE ADVANTAGE
UT740409OtherU002 DESERET MUTUAL
UT942938348KE1OtherU003 EDUCATRS MUTUAL
UT107011057101OtherU006 INTRMT HEALTH CARE
UT942938348KE1OtherU003 EDUCATRS MUTUAL
UTQ07205Medicare UPIN