Provider Demographics
NPI:1093776890
Name:KEANE, SILE
Entity Type:Individual
Prefix:
First Name:SILE
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 1:74 BRICK BLVD
Mailing Address - Street 2:PO BOX 1599
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-7984
Mailing Address - Country:US
Mailing Address - Phone:732-920-9050
Mailing Address - Fax:732-920-9051
Practice Address - Street 1:74 BRICK BLVD
Practice Address - Street 2:SUITE 117, BUILDING 4
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-7984
Practice Address - Country:US
Practice Address - Phone:732-920-9050
Practice Address - Fax:732-920-9051
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC051823001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ065049TB1Medicare ID - Type Unspecified
NJP74842Medicare UPIN