Provider Demographics
NPI:1578786430
Name:KEEGAN, STAELA M (LSW)
Entity Type:Individual
Prefix:MS
First Name:STAELA
Middle Name:M
Last Name:KEEGAN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 OAK ST
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1351
Mailing Address - Country:US
Mailing Address - Phone:973-284-1971
Mailing Address - Fax:
Practice Address - Street 1:777 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-1242
Practice Address - Country:US
Practice Address - Phone:973-594-0125
Practice Address - Fax:973-594-0536
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL01162300104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker