Provider Demographics
NPI:1467197905
Name:SHOULDERS, KEENAN W (LMSW)
Entity Type:Individual
Prefix:
First Name:KEENAN
Middle Name:W
Last Name:SHOULDERS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1574 CROTONA PARK E PH
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-4806
Mailing Address - Country:US
Mailing Address - Phone:267-902-0460
Mailing Address - Fax:
Practice Address - Street 1:1574 CROTONA PARK E PH
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-4806
Practice Address - Country:US
Practice Address - Phone:267-902-0460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty