Provider Demographics
NPI:1154872430
Name:KEETCH, ANITA (AT)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:KEETCH
Suffix:
Gender:F
Credentials:AT
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 968
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84029-0968
Mailing Address - Country:US
Mailing Address - Phone:801-231-9660
Mailing Address - Fax:
Practice Address - Street 1:311 RANCH RD
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84029-9431
Practice Address - Country:US
Practice Address - Phone:801-231-9660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6390707-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer