Provider Demographics
NPI:1073917753
Name:KEENAN, NICOLE M (MHA, LPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:KEENAN
Suffix:
Gender:F
Credentials:MHA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 SWEETFERN CT
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3740
Mailing Address - Country:US
Mailing Address - Phone:732-673-6920
Mailing Address - Fax:
Practice Address - Street 1:795 WOODLANE RD
Practice Address - Street 2:301
Practice Address - City:WESTAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08060-3832
Practice Address - Country:US
Practice Address - Phone:609-267-1377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00206800101YM0800X
NJ37PC00585400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health