Provider Demographics
NPI:1679105639
Name:KEATING, COURTNEY (BCBA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:KEATING
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 BOSTON TPKE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-5970
Mailing Address - Country:US
Mailing Address - Phone:508-443-0018
Mailing Address - Fax:
Practice Address - Street 1:180 WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-2591
Practice Address - Country:US
Practice Address - Phone:413-271-3056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-19-39537103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11011165AMedicaid