Provider Demographics
NPI:1750455044
Name:KEANE, WILLIAM MICHAEL (PHD,)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:KEANE
Suffix:
Gender:M
Credentials:PHD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-3411
Mailing Address - Country:US
Mailing Address - Phone:617-926-6664
Mailing Address - Fax:617-522-0905
Practice Address - Street 1:17 SPRING ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-3411
Practice Address - Country:US
Practice Address - Phone:617-926-6664
Practice Address - Fax:617-522-0905
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1976103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical