Provider Demographics
NPI:1649721358
Name:KEOUGH, ANNA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:KEOUGH
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 1:4765 LORI LN
Mailing Address - Street 2:
Mailing Address - City:PINCKNEY
Mailing Address - State:MI
Mailing Address - Zip Code:48169-9380
Mailing Address - Country:US
Mailing Address - Phone:734-433-9014
Mailing Address - Fax:734-433-1989
Practice Address - Street 1:5840 INTERFACE DR STE 400
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9176
Practice Address - Country:US
Practice Address - Phone:734-627-8001
Practice Address - Fax:734-433-1989
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009647225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201009647OtherSTATE LISCENSE NUMBER