Provider Demographics
NPI:1154705820
Name:POMEROY, KEILAH CATHERINE (LCSW)
Entity type:Individual
Prefix:
First Name:KEILAH
Middle Name:CATHERINE
Last Name:POMEROY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 389
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:MT
Mailing Address - Zip Code:59741-0389
Mailing Address - Country:US
Mailing Address - Phone:064-672-2452
Mailing Address - Fax:
Practice Address - Street 1:207 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:MT
Practice Address - Zip Code:59741-2241
Practice Address - Country:US
Practice Address - Phone:406-672-2452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12177101Y00000X
WALW60651917104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2178044Medicaid