Provider Demographics
NPI:1942662440
Name:MCCLOUD, KEEGAN
Entity Type:Individual
Prefix:
First Name:KEEGAN
Middle Name:
Last Name:MCCLOUD
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 1:1507 NE 77TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64118-1924
Mailing Address - Country:US
Mailing Address - Phone:913-710-3949
Mailing Address - Fax:
Practice Address - Street 1:1507 NE 77TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-1924
Practice Address - Country:US
Practice Address - Phone:913-710-3949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
KS14-03000225200000X
MO2016005668225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician