Provider Demographics
NPI:1710147418
Name:KEENAN, JAMES W (MS, LP)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:KEENAN
Suffix:
Gender:M
Credentials:MS, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 LILAC DR N
Mailing Address - Street 2:SUITE 130
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4700
Mailing Address - Country:US
Mailing Address - Phone:612-874-6746
Mailing Address - Fax:612-874-6745
Practice Address - Street 1:820 LILAC DR N
Practice Address - Street 2:SUITE 130
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4700
Practice Address - Country:US
Practice Address - Phone:612-874-6746
Practice Address - Fax:612-874-6745
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3544103TC2200X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN26A04KEOtherBLUE CROSS BLUE SHIELD
MN118817800Medicaid