Provider Demographics
NPI:1902136955
Name:KECK, KRYSTEN (MSW)
Entity Type:Individual
Prefix:
First Name:KRYSTEN
Middle Name:
Last Name:KECK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2526 SEYMOUR AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3159
Mailing Address - Country:US
Mailing Address - Phone:307-634-9653
Mailing Address - Fax:307-638-8256
Practice Address - Street 1:2508 E FOX FARM RD
Practice Address - Street 2:STE 1A
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-2559
Practice Address - Country:US
Practice Address - Phone:307-634-9653
Practice Address - Fax:307-638-8256
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106079100Medicaid