Provider Demographics
NPI:1942671128
Name:KECK, ELIZABETH VICTORIA
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:VICTORIA
Last Name:KECK
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 1:2250 NW 26TH ST
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-5503
Mailing Address - Country:US
Mailing Address - Phone:507-456-8802
Mailing Address - Fax:507-977-2373
Practice Address - Street 1:2250 NW 26TH ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-5503
Practice Address - Country:US
Practice Address - Phone:507-456-8802
Practice Address - Fax:507-977-2373
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN129921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical