Provider Demographics
NPI:1912025065
Name:KEANE, GRETCHEN
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:KEANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26W171 ROOSEVELT ROAD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187
Mailing Address - Country:US
Mailing Address - Phone:630-909-7370
Mailing Address - Fax:630-909-7371
Practice Address - Street 1:26W171 ROOSEVELT ROAD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187
Practice Address - Country:US
Practice Address - Phone:630-909-7370
Practice Address - Fax:630-909-7371
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILGP31110599P225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist