Provider Demographics
NPI:1609291517
Name:KEENAN, GEORGE
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:KEENAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 TUOLUMNE ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-4641
Mailing Address - Country:US
Mailing Address - Phone:707-648-8121
Mailing Address - Fax:707-648-8129
Practice Address - Street 1:225 AVIAN DR APT B
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-4976
Practice Address - Country:US
Practice Address - Phone:707-557-8975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-28
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101Y00000X
CA33714225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist