Basic Information
| Provider Information | |||||||||
| NPI: | 1649584509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEELEY | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.S., LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2304 E BURNSIDE ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141677 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2304 E BURNSIDE ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032289229 | ||||||||
| FaxNumber: | 5032289558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2010 | ||||||||
| LastUpdateDate: | 01/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C2662 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.