Provider Demographics
NPI:1083160105
Name:KEANE, NICOLE
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:KEANE
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 1:8513 LUCUYA WAY UNIT 302
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-1136
Mailing Address - Country:US
Mailing Address - Phone:561-856-4055
Mailing Address - Fax:
Practice Address - Street 1:13700 58TH ST N STE 207
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3757
Practice Address - Country:US
Practice Address - Phone:877-823-4283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician