Basic Information
| Provider Information | |||||||||
| NPI: | 1790093417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEEN | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | LORRAINE | ||||||||
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| Credential: | AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 545 WILD HORSE LN | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997096700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075900689 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3830 S CUSHMAN ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997017530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074521575 | ||||||||
| FaxNumber: | 9074551460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2010 | ||||||||
| LastUpdateDate: | 09/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 246RP1900X | 36334 | AK | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Pathology | Phlebotomy |
No ID Information.