Provider Demographics
NPI:1679230643
Name:KEANE, HEATHER ANN
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:KEANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5554 RESEDA BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-6212
Mailing Address - Country:US
Mailing Address - Phone:818-705-5522
Mailing Address - Fax:
Practice Address - Street 1:6004 WALDEN DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-6370
Practice Address - Country:US
Practice Address - Phone:865-766-5775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician