Provider Demographics
NPI:1336308998
Name:KEATING, EDWARD THOMAS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:THOMAS
Last Name:KEATING
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 NE 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2425
Mailing Address - Country:US
Mailing Address - Phone:503-504-9499
Mailing Address - Fax:
Practice Address - Street 1:516 SE MORRISON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2327
Practice Address - Country:US
Practice Address - Phone:503-504-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-08
Last Update Date:2008-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR29511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR2951OtherBOARD OF CLINICAL SOCIAL WORK