Provider Demographics
NPI:1083090153
Name:KEENEN, TAYLOR GRACE (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:GRACE
Last Name:KEENEN
Suffix:
Gender:F
Credentials:MED, BCBA
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 1432
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-1432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19800 VILLAGE OFFICE CT
Practice Address - Street 2:#104
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1872
Practice Address - Country:US
Practice Address - Phone:541-306-3483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1-17-25289103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500690196Medicaid