Provider Demographics
NPI:1861998833
Name:KEETON, CIARA MAE
Entity type:Individual
Prefix:
First Name:CIARA
Middle Name:MAE
Last Name:KEETON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5475 MARK DABLING BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-3847
Mailing Address - Country:US
Mailing Address - Phone:719-641-0448
Mailing Address - Fax:
Practice Address - Street 1:5475 MARK DABLING BLVD STE 102
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3847
Practice Address - Country:US
Practice Address - Phone:719-641-0448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-25-80082103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1437321189Medicaid