Provider Demographics
NPI:1881200962
Name:LOVE, KEENAN THOMAS (ATC)
Entity Type:Individual
Prefix:
First Name:KEENAN
Middle Name:THOMAS
Last Name:LOVE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SAGAMORE LN UNIT 204
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-3842
Mailing Address - Country:US
Mailing Address - Phone:860-729-4174
Mailing Address - Fax:
Practice Address - Street 1:80 SHUNPIKE RD UNIT 202
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-4402
Practice Address - Country:US
Practice Address - Phone:860-632-1792
Practice Address - Fax:860-632-1802
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0006402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer