Provider Demographics
NPI:1811191414
Name:KEANE, THERESA (PHD, NPP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KEANE
Suffix:
Gender:F
Credentials:PHD, NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 GRACE WAY
Mailing Address - Street 2:
Mailing Address - City:OLIVEBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12461-5236
Mailing Address - Country:US
Mailing Address - Phone:917-453-3684
Mailing Address - Fax:917-453-3684
Practice Address - Street 1:7750 E BROADWAY BLVD STE A100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3901
Practice Address - Country:US
Practice Address - Phone:520-327-1529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011974-1103TC0700X
NYF401198363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical