Provider Demographics
NPI:1437390309
Name:O'LEARY, KEITH DANIEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:DANIEL
Last Name:O'LEARY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 CHRISTIAN AVE
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790
Mailing Address - Country:US
Mailing Address - Phone:631-751-3149
Mailing Address - Fax:631-689-6844
Practice Address - Street 1:236 CHRISTIAN AVE
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-1234
Practice Address - Country:US
Practice Address - Phone:631-751-3149
Practice Address - Fax:631-689-6844
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0035661103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist