Provider Demographics
NPI:1548650930
Name:KEETON, KIMLY (LCSW, LCAC)
Entity type:Individual
Prefix:
First Name:KIMLY
Middle Name:
Last Name:KEETON
Suffix:
Gender:F
Credentials:LCSW, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 BEAUTY CREEK RUN
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-7049
Mailing Address - Country:US
Mailing Address - Phone:219-741-8895
Mailing Address - Fax:
Practice Address - Street 1:809 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3431
Practice Address - Country:US
Practice Address - Phone:219-898-5646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-23
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001395A101YA0400X
IN34006482A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)