Provider Demographics
NPI:1184066557
Name:KEEGAN, MELISSA (LMSW)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:
Last Name:KEEGAN
Suffix:
Gender:F
Credentials:LMSW
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 2141
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83353-2141
Mailing Address - Country:US
Mailing Address - Phone:208-731-8233
Mailing Address - Fax:
Practice Address - Street 1:141 CITATION WAY
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-5103
Practice Address - Country:US
Practice Address - Phone:208-731-8233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-31372104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker