Provider Demographics
NPI:1679883409
Name:KEYES, SHANA MARLENE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:MARLENE
Last Name:KEYES
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 1:1832 SCR 84-A
Mailing Address - Street 2:
Mailing Address - City:BAY SPRING
Mailing Address - State:MS
Mailing Address - Zip Code:39422
Mailing Address - Country:US
Mailing Address - Phone:601-201-7933
Mailing Address - Fax:601-469-9927
Practice Address - Street 1:4010 O'FERRAL STREET
Practice Address - Street 2:SUITE 110
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-201-7933
Practice Address - Fax:601-469-9927
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC23331041C0700X
MST0308106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist