Provider Demographics
NPI:1306192380
Name:KEANE, LESLIE N (LMT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:N
Last Name:KEANE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1042 SUTTON RD UNIT 2B
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-8344
Mailing Address - Country:US
Mailing Address - Phone:734-363-8457
Mailing Address - Fax:
Practice Address - Street 1:1042 SUTTON RD
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-8344
Practice Address - Country:US
Practice Address - Phone:734-363-8457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501014525APP21225700000X
MIL2274798101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor