Provider Demographics
NPI:1073352696
Name:INGMIRE, KEELYN MARIE (EDS, NCSP)
Entity type:Individual
Prefix:MS
First Name:KEELYN
Middle Name:MARIE
Last Name:INGMIRE
Suffix:
Gender:F
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 BELTRAMI AVE NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-2806
Mailing Address - Country:US
Mailing Address - Phone:218-368-6802
Mailing Address - Fax:
Practice Address - Street 1:1419 BELTRAMI AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-2806
Practice Address - Country:US
Practice Address - Phone:218-368-6802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1019515103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool