Provider Demographics
NPI:1760436125
Name:KELLER, SUSAN CLARK (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:CLARK
Last Name:KELLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:F
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:307 1ST AVE EAST
Mailing Address - Street 2:STE 3
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-4965
Mailing Address - Country:US
Mailing Address - Phone:406-257-3877
Mailing Address - Fax:406-257-3907
Practice Address - Street 1:307 1ST AVE EAST
Practice Address - Street 2:STE 3
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4965
Practice Address - Country:US
Practice Address - Phone:406-257-3877
Practice Address - Fax:406-257-3907
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT582LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0502537Medicaid