Provider Demographics
NPI:1063477719
Name:KEENAN, MARY BRIDGET (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:BRIDGET
Last Name:KEENAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:71 HAYNES ST
Mailing Address - Street 2:MANCHESTER MEMORIAL HOSPITAL
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4131
Mailing Address - Country:US
Mailing Address - Phone:860-647-6832
Mailing Address - Fax:860-647-6831
Practice Address - Street 1:150 N MAIN ST
Practice Address - Street 2:SUITE 130
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2086
Practice Address - Country:US
Practice Address - Phone:860-533-3434
Practice Address - Fax:860-647-6829
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT0041361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004025177Medicaid
CT800002415Medicare ID - Type Unspecified
CT004025177Medicaid