Provider Demographics
NPI:1891139226
Name:KILGORE, KEITH E (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:E
Last Name:KILGORE
Suffix:
Gender:M
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:USA MEDDAC
Mailing Address - Street 2:11050 MOUNT BELVEDERE BLVD
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602
Mailing Address - Country:US
Mailing Address - Phone:315-772-6191
Mailing Address - Fax:
Practice Address - Street 1:USA MEDDAC
Practice Address - Street 2:11050 MOUNT BELVEDERE BLVD
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-6191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY082630104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker