Provider Demographics
NPI:1073565453
Name:KEENAN, CAROL A (PT)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:KEENAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 IDLEWILD BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-2698
Mailing Address - Country:US
Mailing Address - Phone:757-784-8343
Mailing Address - Fax:
Practice Address - Street 1:2105 IDLEWILD BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-2698
Practice Address - Country:US
Practice Address - Phone:757-784-8343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003508225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA191907OtherANTHEM BCBS
VA00X481P02Medicare PIN
VA190001395Medicare ID - Type UnspecifiedTRAILBLAZER HEALTH