Provider Demographics
NPI:1760549091
Name:BISHOP, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:BISHOP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 333
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-0333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1180 HIGHWAY WW
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-9589
Practice Address - Country:US
Practice Address - Phone:660-886-2253
Practice Address - Fax:660-886-6601
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW0013191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical