Provider Demographics
NPI:1891338315
Name:WIMBERLEY, KEELIE
Entity Type:Individual
Prefix:
First Name:KEELIE
Middle Name:
Last Name:WIMBERLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 BETHESDA DR UNIT 4
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-0815
Mailing Address - Country:US
Mailing Address - Phone:740-201-2324
Mailing Address - Fax:
Practice Address - Street 1:930 BETHESDA DR UNIT 4
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-0815
Practice Address - Country:US
Practice Address - Phone:740-201-2324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.22041151041C0700X, 101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator