Provider Demographics
NPI:1679900765
Name:KEANE, JOHN IV (LMSW,BA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KEANE
Suffix:IV
Gender:M
Credentials:LMSW,BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 E MAIN ST
Mailing Address - Street 2:4TH FLOOR ADMINISTRATION
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2310
Mailing Address - Country:US
Mailing Address - Phone:203-574-9000
Mailing Address - Fax:203-574-9006
Practice Address - Street 1:402 E MAIN ST
Practice Address - Street 2:WATERBURY OP ADULT SERVICES
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1701
Practice Address - Country:US
Practice Address - Phone:203-755-1143
Practice Address - Fax:203-755-1447
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 1041C0700X
CT2166104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPENDINGOtherAETNA BEHAVIORAL HEALTH
CT008064408Medicaid
CT060669107OtherOPTUM BEHAVIORAL HEALTH/UBH WELLMORE GRP/FACILITY
CT060669107OtherHEALTHYCT WELLMORE GRP/FACILITY
CTNOT ELIGIBLEOtherMHN TRICARE NORTH
CT060669107OtherUBH-CONNECTICARE WELLMORE GRP/FACILITY
CT060669107OtherANTHEM BEHAVIORAL HEALTH WELLMORE GRP/FACILITY
CTPENDINGOtherCIGNA BEHAVIORAL HEALTH
CT13671836OtherCAQH
CTD339123 WATERBURYOtherBEACON HEALTH STRATEGIES
CTNOT ELIGIBLEOtherMHN MANAGED HEALTH NETWORK
CT060669107OtherUBH-OXFORD FREEDOM/LIBERTY
CT060669107OtherUBH-UNITED HEALTHCARE
CT060669107OtherANTHEM BEHAVIORAL HEALTH WELLMORE GRP/FACILITY