Provider Demographics
NPI:1417052465
Name:KEANE, KATHLEEN B (LP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:B
Last Name:KEANE
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5696 WINDMILL DR
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-2284
Mailing Address - Country:US
Mailing Address - Phone:651-714-8007
Mailing Address - Fax:
Practice Address - Street 1:1310 HIGHWAY 96 E
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3624
Practice Address - Country:US
Practice Address - Phone:651-714-8007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3569103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist