Provider Demographics
NPI:1962157487
Name:IMBODEN, KEELY
Entity type:Individual
Prefix:
First Name:KEELY
Middle Name:
Last Name:IMBODEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEELY
Other - Middle Name:
Other - Last Name:MAYNARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1103 N ILLINOIS ST STE B
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:AR
Mailing Address - Zip Code:72432-3023
Mailing Address - Country:US
Mailing Address - Phone:870-931-8412
Mailing Address - Fax:
Practice Address - Street 1:1103 N ILLINOIS ST STE B
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:AR
Practice Address - Zip Code:72432-3023
Practice Address - Country:US
Practice Address - Phone:870-931-8412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101YP2500X
ARA2208025101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health