Provider Demographics
NPI:1831108943
Name:KEESLAR, GLORIA M (LCPC)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:M
Last Name:KEESLAR
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3106 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5067
Mailing Address - Country:US
Mailing Address - Phone:309-786-6685
Mailing Address - Fax:
Practice Address - Street 1:3106 22ND AVE
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5067
Practice Address - Country:US
Practice Address - Phone:309-786-6685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0003721881OtherBCBS PROVIDER NUMBER