Provider Demographics
NPI:1083249940
Name:KEANE, EDWARD MARTIN (LPC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:MARTIN
Last Name:KEANE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N13226 HOGAN LN
Mailing Address - Street 2:
Mailing Address - City:TREMPEALEAU
Mailing Address - State:WI
Mailing Address - Zip Code:54661-8346
Mailing Address - Country:US
Mailing Address - Phone:608-931-4765
Mailing Address - Fax:
Practice Address - Street 1:N13226 HOGAN LN
Practice Address - Street 2:
Practice Address - City:TREMPEALEAU
Practice Address - State:WI
Practice Address - Zip Code:54661-8346
Practice Address - Country:US
Practice Address - Phone:608-931-4765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178005790101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional