Provider Demographics
NPI:1316651946
Name:KEOVILAY, MANDY
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:KEOVILAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 KINGS COUNTY DR
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-3579
Mailing Address - Country:US
Mailing Address - Phone:559-410-1815
Mailing Address - Fax:
Practice Address - Street 1:530 KINGS COUNTY DR
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93290
Practice Address - Country:US
Practice Address - Phone:559-754-4847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1202451041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical